Laurel Patient Registration Form

Laurel Foot & Ankle Center

14440 Cherry Lane Court
Suite 104
Laurel, MD 20707

www.laurelfootandanklecenter.com

301-953-3668
New Patient Registration

Please fill in the form below
Patient Name

First NameLast Name
M.I.
SSN
Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Cell Phone
Email
example@example.com
Marital Status
Spouse's Name
Financially Responsible Person, If Different From Patient
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Person, Other Than Spouse, to Contact in Case of An Emergency
Relationship
Contact's Phone
Please enter a valid phone number.
Referring Physician's Name
Physician's Phone
Please enter a valid phone number.
Your Primary Physician's Name
Physician's Phone
Please enter a valid phone number.
Insurance Coverage
Primary Ins. Co.
Name of Policy Holder
Relationship
Policy Holder's DOB

MonthDayYear
Date
Group#
Policy ID#
Secondary Ins. Co
Name of Polley Holder
Relationship
Policy Holder's DOB

MonthDayYear
Date
Policy ID#
Group#
Policy Holder's Employer
Employer's Phone #
Please enter a valid phone number.
Northern Virginia Foot & Ankle Associates

8221 Old Courthouse Rd, Vienna, VA 22182, USA

www.novafoot.com

703-734-1311
Date

MonthDayYear
Date
Signature

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PRIVATE INSURANCE AUTHORIZATION FOR ASSIGNMENT OF BENEFITS AND INFORMATION RELEASE
I, the undersigned, authorize payment of medical benefits to Northern Virginia Foot and Ankle Associates/Laurel Foot and Ankle Center for any services furnished to me by the physicians. I understand I am financially responsible for any amount not covered1 by my health insurance contract. I also authorize you to release to my insurance company any information concerning health care, advice, treatment, or supplies provided to me. This information will be used for the purpose of evaluating and administering claim benefits, including worker comp claims. I permit a copy of this authorization to be used in place of the original.
Date

MonthDayYear
Date
Signature

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MEDICAL HISTORY
PATIENT'S NAME:
Reason for your visit: Date when symptoms began and a description of the symptoms
If problem is accident related, indicate date accident occurred and place of injury
Have you been treated by another physician for this problem? If yes, list physician's name and treatment
Past Medical History (check all that apply)
AIDS/HIV

YesNo
Anemia

YesNo
Arthritis

YesNo
Artificial Heart Valve/ Joints

YesNo
Asthma

YesNo
Back Problems

YesNo
Bleeding Disorder

YesNo
Cancer

YesNo
Chemical Dependency

YesNo
Chest Pain

YesNo
Circulatory Problems

YesNo
Diabetes

YesNo
Epilepsy

YesNo
Eye Problems

YesNo
Gout

YesNo
Headaches

YesNo
Heart Disease

YesNo
High Blood Pressure

YesNo
Kidney Problems

YesNo
Liver Disease

YesNo
Low Blood Pressure

YesNo
Nervous Problems

YesNo
Psychiatric Care

YesNo
Respiratory Disease

YesNo
Rheunatic Fever

YesNo
Shortness of Breath

YesNo
Sinus Problems

YesNo
Stroke

YesNo
Tuberculosis

YesNo
Ulcers

YesNo
Varicose Veins

YesNo
Weight Loss, Unexplained

YesNo
Other Past Medical History:
Have you had any surgery? If yes, please list all past surgeries:
Are you currently taking any medications? If yes, please list them:
Are you currently taking any medications? If yes, please list them:
Do you have any medication allergies? If yes, please list and describe reaction:
Do you experience abnormal bleeding with surgery, cuts, extractions, or trauma?

YesNo
Are you, or is there any chance you may be pregnant?

YesNo
Put a check by any conditions below that any blood relatives have or had

DiabetesFood ProblemsHeart DiseaseStrokeGoutArthritisTBCancerHigh Blood PressureKidney Disease
Other
Shoe Size
Shoe Width
Weight
Height
Policy for Payment of Medical Services and Products Agreement
Due to the vast amount of information, the daily changes in laws, regulations, and policies, we cannot guarantee that all services at all times will be covered by your insurance company. In order to achieve our goal of assuring that each patient receives the best possible care and to help our patient with their allowed medical benefits, we ask the assistance and attention of all our patients. It is important that each patient knows what their insurance plan offers for care, the services th'at their plan will pay for, and the changes that occur within their insurance plan. It is also important that each patient keeps us informed of current changes with their insurance, billing address changes, and that each patient provides us with proof of insurance, as well as a photo identification card. In the case where it is a requirement by an insurance company that a patient be seen with a referral and in the case where treatment plans must be submitted, it is the responsibility of the patient to see that these forms are obtained and given to the appropriate person in our office.In the case that the referral/treatment plan is not obtained and services are rendered the patient will be held financially responsible. As with any service, all charges are the responsibility of each patient from the date services rendered and payment in full is expected at the time of service is provided. To assist our patients, we accept Visa, MasterCard, American Express, Discover, Cash, and Checks as
forms of payment.
PLEASE READ AND INITIAL EACH LINE BELOW ACKNOWLEDING YOU HA VE READ ALL POLICIES.
Initials* , CO PAYMENTS: Your insurance REQUIRES that we collect your designated co-pay at the time of service. Please be prepared to pay the co-pay at each visit.
Initials* , DEDUCTIBLES AND CO-INSURANCE: We may collect your deductible and co-insurance at the time of service. We will bill your insurance company. Patient Responsibility portions of your bill are to be paid within 90 days,
Initials* , SELF-PAY/UNINSURED: Self-pay accounts shall exist if a patient has no insurance coverage or no evidence of insurance coverage. For new patients, a payment of $346.00 is required on the day of your appointment before being seen by the health care provider. If you are unable to pay the $346.00 please contact the billing office prior to your appointment. A discount on regular fees is offered for payment made at the time of service.
Initials* , REFERRALS: If your insurance plan requires a referral from your primary care physician it is your responsibility to obtain it prior to your appointment and to have it with you at the time of the appointment. If you do not have your referral, YOU MAY BE REQUIRED TO RESCHEDULE.
Initials* , RETURNED CHECK FEES: Any returned check from the bank for non-payment (insufficient funds) shall result in the patient's account being assessed a $40.00 fee per check returned.
Initials* , FORMS/PAPERWORK: There is a $40.00 pre-payment per form fee for the completion of paperwork or forms relating to disability, FMLA, etc. This fee is collected prior to completion of the paperwork, and for each time the paperwork is required. Allow seven working days for completion of forms. Any forms needed within 48 hours from the time it Was given to our staff will need to pre-pay an additional $20.00 rush fee.
Initials* , OMV HANDICAP PARKING APPLICATIONS: There is a $10.00 fee for ALL DMV handicap parking applications.
Initials* , NO SHOW FEE: You will be charged a $75.00 fee if you fail to cancel your appointment within 24 hours of your scheduled appointment or do not show up for your scheduled appointment.
Initials* , SURGERY CANCELATION FEE: Any surgeries canceled within 7 business days of the scheduled surgery date will incur a cancellation fee of $500.00. (Fee will be waived if surgery is canceled due to a death in the family, illness, or if the patient is not cleared for surgery)
RESPONSIBLE PARTY SIGNATURE

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Date

MonthDayYear
Date
Patient Name (if different from Responsible Party):
Patient statement: To the best of my knowledge, the information I will provide is accurate and complete.
Signature

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Date

MonthDayYear
Date
Type a question
I am aware of my HIPAA Rights (you can request a copy of your privacy rights at the front desk)
Signature

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Date

MonthDayYear
Date
How did you hear about us?

We would sincerely appreciate if you could take a few moments to complete the following questionnaire. This information will be used to improve our outreach program. Thank you for your time!
A referring doctor
Name
If a doctor did not refer you to our practice, please check an option below:
A friend who is a current patient
Name
Magazine article or advertisement Please ' specify:
Google / Internet Search
Insurance Carrier
Facebook
Help
Other
CONSENT TO LEAVE MESSAGES
I understand that my healthcare information is protected. I understand that, in order for the Laurel Foot & Ankle/ NOVA Foot & Ankle team to leave detailed messages containing specific podiatric care information on my voicemail, through text messages, or e-mail, I give my permission to do so.

Consent for Leaving Messages
I give my permission for messages to be left on my phone number and E-mail below:
Phone Number
Please enter a valid phone number.
Email
example@example.com
Regarding the following:

1. Appointment Reminders/Changes Account
2. Payments/Balances
3. Cost Estimates
4. Needed Treatment/Completed Treatment
Date

MonthDayYear
Date
Printed Name (Patient/Parent)
Signature (Patient/Parent)

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Should be Empty:

New Patient Registration

Insurance Coverage

MEDICAL HISTORY

Policy for Payment of Medical Services and Products Agreement

PLEASE READ AND INITIAL EACH LINE BELOW ACKNOWLEDING YOU HA VE READ ALL POLICIES.

Patient statement: To the best of my knowledge, the information I will provide is accurate and complete.

I am aware of my HIPAA Rights (you can request a copy of your privacy rights at the front desk)

How did you hear about us?

If a doctor did not refer you to our practice, please check an option below:

CONSENT TO LEAVE MESSAGES