FAPO NEW PT PAPERWORK

Welcome to our office! We are very pleased to have you with us. Please fill in all the appropriate blanks below. This information is important for your health and our records. It also helps in expediting your insurance payment. If you need help please do not hesitate to ask.

PLEASE HAVE YOUR INSURANCE CARD AND PHOTO ID AVAILABLE FOR THE RECEPTIONIST TO COPY.

PATIENT FIRST NAME*

PATIENT LAST NAME*

MI

SEX*

BIRTH DATE*

Date

AGE

HOME ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

HOME PHONE #

CELL PHONE #*

SOCIAL SECURITY NUMBER*

PATIENT'S EMAIL ADDRESS*

example@example.com

MARITAL STATUS

NAME OF SPOUSE/PARENT OR GUARDIAN

SPOUSE'S/GUARDIAN'S SOCIAL SECURITY NUMBER

SPOUSE'S/GUARDIAN'S BIRTH DATE

Date

SPOUSE/GUARDIANS PHONE #

Please enter a valid phone number.

EMERGENCY CONTACT PERSON NAME AND TELEPHONE #*

PATIENT'S EMPLOYER (OR PARENT/GUARDIAN)

BUISNESS ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

BUISNESS PHONE #

Please enter a valid phone number.

OCCUPATION

PRIMARY INSURANCE COMPANY*

PRIMARY INSURANCE COMPANY ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

SUBSCRIBER'S NAME (IF NOT THE PATIENT)

RELATIONSHIP TO PATIENT

DATE OF BIRTH OF SUBSCRIBER

Date

MEMBER ID NUMBER*

GROUP NUMBER*

SECONDARY INSURANCE COMPANY

SECONDARY INSURANCE COMPANY ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

SUBSCRIBER'S NAME (IF NOT THE PATIENT)

RELATIONSHIP TO PATIENT

DATE OF BIRTH OF SUBSCRIBER

Date

MEMBER ID NUMBER

GROUP NUMBER

FAMILY PHYSICIAN*

FAMILY PHYSICIAN TELEPHONE #

DID THEY REQUSET YOU TO BE SEEN IN OUR OFFICE?

FORMER PODIATRIST

WHAT WERE YOU TREATED FOR?

WHOM CAN WE THANK FOR REFERRING YOU TO OUR PRACTICE?

I HEREBY GIVE MY PERMISSION TO THE DOCTORS OF FOOT AND ANKLE PHYSICIANS OF OHIO TO EXAMINE, PHOTOGRAPH, ADMINISTER TREATMENT AND PERFORM SUCH MINOR OPERATIVE PROCEDURES AS MAY BE DEEMED NECESSARY IN THE DIAGNOSIS AND/OR TREATMENT OF MY FOOT PROBLEM. I AUTHORIZE THE RELEASE OF MEDICAL INFORMATION NECESSARY TO PROCESS ANY CLAIM. I AUTHORIZE PAYMENT OF MEDICAL/SURGICAL BENEFITS DIRECTLY TO FOOT AND ANKLE PHYSICIANS OF OHIO.

SIGNATURE*

DATE*

Date

PARENT/GUARDIANS SIGNATURE

DATE

Date

IS THE REASON FOR YOUR VISIT TODAY RELATED TO A WORK INJURY/WORKERS COMPENSATION CLAIM?*

YESNO

IF YES, WHAT IS YOUR WORKERS COMPENSATION CLAIM #?

IF YES, WHO IS YOUR PHYSICIAN OF RECORD?

IF YES, WHAT IS THE DATE OF INJURY?

Date

Why are you seeing the Doctor today?*

DO YOU HAVE ANY MEDICATION ALLERGIES?*

YESNO

IF YES, WHAT MEDICATIONS ARE YOU ALLERGIC TO?

DO YOU CURRENTLY OR HAVE YOU EVER SMOKED?*

YESNO

IF YES, FOR HOW LONG HAVE YOU SMOKED?

IF YOU QUIT, HOW LONG AGO?

DO YOU HAVE AN ALCOHOL OR DRUG ADDICTION?*

YESNO

IF YES, WHICH?

DO YOU HAVE HIGH BLOOD PRESSURE?*

YESNO

DO YOU HAVE DIABETES?*

YESNO

IF YES, DO YOU USE INSULIN?*

YESNO

HAVE YOU EVER HAD A HEART ATTACK OR HEART SURGERY?*

YESNO

IF YES, WHEN?

DO YOU HAVE HEPATITIS A, B, OR C?*

YESNO

IF YES, WHICH?

DO YOU HAVE HIV OR AIDS?*

YESNO

HAVE YOU EVER HAD A BLOOD CLOT?*

YESNO

PLEASE LIST ANY PREVIOUS FOOT/ANKLE SURGERIES ALONG WITH THE DATE OF SURGERY*

PLEASE LIST ANY MEDICATIONS*

NAME OF PREFERRED PHARMACY*

ADDRESS OF PHARMACY

PHARMACY TELEPHONE #

Shoe size*

Height*

Weight*

IF THERE IS ANY ADDITIONAL INFORMATION YOU WOULD LIKE US TO KNOW, PLEASE LIST IT HERE

Financial Policy for Foot and Ankle Physicians of Ohio

Thank you for choosing our office to provide you with medical care. We are committed to serving you with skill and high quality care. The medical services provided by our office are services you have elected to receive which may imply a financial responsibility on your part.

INSURANCE: We participate in most insurance plans, however we encourage you to check with your insurance carrier to confirm our participation. We require that you bring your insurance card with you to each visit so that we may confirm your eligibility. If you do not present your card and it is determined that you do not have coverage, you will be responsible for the charges incurred at the time of the service. You are responsible for keeping the office informed as to any changes in your insurance contract or carrier information. Please be aware that your insurance policy is a contract between you and your insurance carrier. We are pleased to provide the service of submitting claims for our patients; however we remind you that you are ultimately responsible for payment of any services provided to you.

COPAYMENTS AND DEDUCTIBLES: Most insurance plans require that the insured patient pay a co-payment for office visits and other specified services such as x-rays and injections. Foot and Ankle Physicians of Ohio is required by the plans we contract with to collect your co-pay and any unmet deductible at the time of your service. Any questions you might have regarding co-payments and deductibles should be directed to your insurance company or your employer's human resources department. Knowing your insurance benefits is your responsibility.

MEDICARE: We are a participating Medicare provider. Medicare, as well as any secondary insurance, will be billed for you. Patients are responsible for paying their annual deductible if not previously met as well as any co-payments, which are usually 20% of the allowed amount for an item or service.

SECONDARY INSURANCE: Your medical claim will be forwarded to any secondary insurance after payment and/or explanation of benefits (EOB) is receivedfromyour primary insurance company.

NON-COVERED SERVICES: Please be aware that some of the services you receive may not be covered or not considered reasonable or necessary by Medicare or other insurers. You are responsible for payments of these services.

REFERRALS/AUTHORIZATIONS: We are required to follow all guidelines of a managed care plan that may require when you visit a specialist, you must have a referral yourprimary care physician prior to seeking specialty care. If your plan requires a referral, and if you do not have a referral from your primary care physician at the time of the visit, you will be financially responsible for all services due in full upon completion of the visit. You may also be given the option to reschedule your appointment.

CLAIM SUBMISSION: We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request in a timely manner. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim.

PATIENT BILLING: You will be sent up to three notices for your financial responsibility (co-insurance/deductible) after payment and/or explanation ofbenefits(EOB)is received from your insurance company/companies. After the third and last notice, your account may be forwarded to collections. Please let the billing officeknowif you have any difficulties resolving your bill. Payment arrangements can be made on a case-by-case basis. We accept the following payment methods: Cash, Check, VISA/MasterCard/Discover, and HSA/HRA. An additional $25.00 will be added to your statement if your check is returned for insufficient funds. In the event your insurance company should happen to send payment to you, the patient, we expect that you would forward it to our office to be applied to your balance.

CHARGES YOU MAY INCUR: If we are asked to complete additional forms or reports for you, there will be additional charges. Form and report completion fees are requestis made. These fees will NOT be billed to your insurance company. Additional charges will be assessed for the following: Disability Forms, FMLA forms, Copies of Medical Records, Returned Checks, Attending Physician Statement, Over-the-counter medical supplies, and Shoe Restocking.

We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment. Patients who fail to show for scheduled appointments or did not notify the office within 24 hours of their appointment time, will be charged a no-show fee of $25. To cancel an appointment, please call our office at (614) 782-3668 and speak to the scheduler. By signing below, I authorize Foot and Ankle Physicians of Ohio to charge my credit card on file.

DURABLE MEDICAL EQUIPMENT/CUSTOM ORTHOTICS: Durable Medical Equipment (DME) and custom orthotics may not be returned.

I have read and agree to abide by the above financial policy and have been given an opportunity to ask questions on any points that I did not understand. I agree to pay Foot and Ankle Physicians of Ohio any balance unpaid by my insurance carrier for myself or the below named person.

ASSIGNMENT OF BENEFITS: I, the undersigned, certify that I (or my dependent) have coverage with my insurance as presented and assign directly to Foot and Ankle Physicians Ohio, all insurance benefits, payable to me for services rendered. I understand that I am responsible for payment of deductibles, co-payments, and/or non- covered services. I hereby authorize the doctor to release all information necessary to secure payment of benefits. I authorize the release of my medical information to my insurance carrier, or requested physician to provide continuity of care. I authorize the use of this signature on all insurance submissions. I understand that itis my responsibility to inform the doctor's office if there is a change in my health insurance information.

Patient's name (Printed)*

Patient's signature*

Date*

Date

FINANCIALLY RESPONSIBLE PARTY (IF NOT THE PATIENT):

Print Name

Signature

Relationship to Patient

I. ACKNOWLEDGEMENT OF PRACTICES NOTICE OF PRIVACY PRACTICES:

BY SUBSCRIBING MY NAME BELOW, I ACKNOWLEDGE THAT I WAS PROVIDE A COPY OF THE NOTICE OF PRIVACY PRACTIVES (NPP) AND THAT I HAVE READ OR HAD THAT OPPORTUNITY TO READ AND UNDERSTAND THE NOTICE OF PRIVACY PRACTIVES (NPP) AND AGREE TO ITS TERMS.

NAME OF PATIENT*

DOB*

Date

SIGNATURE OF PATIENT/PARENT/GUARDIAN*

Date*

Date

II. DESIGNATION OF CERTAIN RELATIVES, CLOSE FRIEDS, AND OTHER CAREGIVERS AS MY PERSONAL REPRESENTATIVE:

I AGREE THAT THE PRACTICE MAY DISCLOSE CERTAIN PIECES OF MY HEALTH INFORMATION TO A PERSONAL REPRESENTATIVE OF MY CHOOSING, SINCE SUCH PERSON IS INVOLVED WITH MY HEALTHARE OR PAYMENT RELATING TO MY HEALTHCARE. IN THAT CASE, THE PHYSICIAN PRACTICE WILL DISCLOSE ONLY INFORMATION THAT IS DIRECTLY RELEVANT TO THE PERSONS INCOLVEMENT WITH MY HEALTHCARE OR PAYMENT RELATING TO MY HEALTH CSRE.

PRINT NAMES OF PERSONAL REPRESENTATIVES

III. REQUEST TO RECIEVE CONFIDENTIAL COMMUNICATIONS BY ALTERNATIVE MEANS:

AS PROVIDED BY PRIVACY RULE SECTION 164.522(b), I HEREBY REQUEST THAT THE PRACTIVE MAKE ALL COMMUNICATIONS TO ME BY THE ALTERNATIVE MEANS THAT I HAVE LISTED BELOW.

HOME TELEPHONE NUMBER

Type a question

OKAY TO LEAVE MESSAGE WITH DETAILED INFORMATIONLEAVE MESSAGE WITH CALL BACK NUMBERS ONLYOther

WRITTEN COMMUNICATION ADDRESS

OK TO MAIL TO THE ADDRESS LISTED ABOVEOK TO EMAIL ME AT (PROVE=DE EMAIL IN "OTHER" LINEOther

IV. THE FOLLOWING PERSONS ARE NOT AUTHORIZED TO RECIEVE MY PATIENT HEALTH INFORMATION

PRINT NAMES OF THOSE NOT AUTHORIZED

V. THE HIPPAA PRIVACY RULE:

The HIPAA Privacy rule requires healthcare providers to take reasonable steps to limit the useor disclosure of, and requests for PHI. I understand that this accounting will not reflect disclosures that are made in the course of the Practice's ordinary health care activities related to providing patient treatment, obtaining payment for its services or its internal operations. Also, the Practice does not have to account for disclosures for which I have executed an Authorization permit ting disclosures of my PHI.

1: The above authorizations are voluntary and I may refuse to agree to their terms ithout affecting any of my rights to recieve healthcare at the practice.

2: These authorizations may be revoked at any time bu notifying the practive in writing at the practices mailing address makres to the attention of "HIPAA Compliance Officer".

3: The revocation of this authorization will not have any effect on disclosures occurring prior to the execution of any revocation.

4: I may see any copy the information described in this form, if I ask for it, and I wil get a copy of this form after I sign it.

5: This form was completely filled in before I signed it and acknowledge that all of my questions were answered to my satisfaction, that I fully understand this suthorization form, and have recieved an executed copy.

6: This authorization is valid as of the date I have signed below and shall remain valid until changed or revoked.

Name of Patient*

Signature*

Date*

Date

FAPO

Foot & Ankle Physicians of Ohio

PATIENT HIPAA ACKNOWLEDGEMENT AND DESIGNATION DISCLOSURE FORM