drmansdorf.com - New Patient Form

New Patient Form
Patient Information
Name

First NameLast Name
Age
Sex
DOB

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone: Home
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Phone: Work
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Phone: Cell
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Email
example@example.com
Driver’s License #
State
Employer
Occupation
Emergency Contact
Phone Number
Please enter a valid phone number.
Referred by
Person Responsible for Payment
Name
If patient is a minor, name of Parent/Guardian
Relationship
DOB

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone: Home
Please enter a valid phone number.
Phone: Work
Please enter a valid phone number.
Phone: Cell
Please enter a valid phone number.
Email
example@example.com
Employer
Occupation
Insurance
Insurance Member Number
Group Number
Insurance Phone Number
Please enter a valid phone number.
Authorization for Medical Treatment, Release of Medical Information to Insurance Company and Assignment of Benefits

I/We do herebyconsent to and authorize the performance of all treatments, surgery and medical services by Dr. Mansdorf, his assistant or his qualified designate which they may deem advisable. I consent to the taking and publication of photographs of my extremities during the course of this treatment forthepurpose of advancing medical education, understanding that my name and personal informationwill not be disclosed.

I authorize Dr. Neil B. Mansdorf to furnish information concerning my illness or injury and direct the insurer to pay without equivocation any and all benefits due as a result of claims billed on my behalf. I am aware that I am personally responsible for all charges and/or balance due not covered by my insurance benefits.If insurance is not billed, I accept full responsibly for thepayment of such services and agree to pay for them, in full, AT THE TIME OF SERVICE, unless other arrangements are made with the Financial Department.
Signature (Patient or Parent/Guardian)

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Date

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Date

“Covered California” Patients
If you are covered by any Covered California care insurance program, you are responsible for determining if Dr. Mansdorf is covered under the plan you have chosen.

Please be aware that while Dr. Mansdorf is a preferred/contracted provider for several of the plans, he is not a provider on all of them. The plan as well as the level/group you have chosen may determine provider coverage.

Dr. Mansdorf is out of network for Covered California exclusive IFP plans, Blue Shield PPO and EPO, Blue Cross PPO, EPO and Pathway X plans. Please note, these plans have higher copays, deductibles and out of pocket costs, and must be paid at time of service.
Signature (Patient or Parent/Guardian)

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Date

MonthDayYear
Date

Financial Policy
Thank you for choosing us as your podiatrist. We are committed to providing you with the highest quality of care. The following is a statement of our financial policy which we request that you review carefully and sign prior to treatment.

Insurance
If you would like us to bill your insurance, we require a photo ID as well as your insurance card at the time of your initial visit. You must bring all insurance cards at the time of your visit. Without them you will be required to pay cash.

You as the patient are responsible to know what insurance plan you have. You must know what podiatric medical benefits and coverage you have at the time of your appointment, including pre authorization, deductible and co-payments. If you do not know what your coverage is, please call your insurance company prior to your appointment to get the information

For all patients with insurance plans for which we are providers, we will bill your insurance company. All copayments and deductibles are due at the time of service. If we find after the appointment that your insurance was not valid, you will be responsible for all fees incurred.

If we are not a provider for your insurance company, we ask that you please pay at the time of service. We will provide you with a receipt to submit to your insurance for reimbursement.

Cash
Payment for all services is due at the time of service unless prior arrangements are made. We accept cash, checks, Master Card and Visa. A valid ID is required.

NSF (Non-Sufficient Funds/Returned Check) Fee
If you present any type of payment instrument or method that is dishonored for any reason by the drawee, we may charge you a $35 fee plus any bank fees incurred by the drawee.

Appointments
Missed/Canceled: Any appointment not canceled within 24 hours (working hours) will be assessed a noninsurance reimbursable fee and must be paid before or at your next appointment.

Fees are as follows:
- Office Visit: $25
- Office Surgery: $50
- Hospital/Surgery Center: $100
Emergency/After Hours: There is a $35 non-insurance reimbursable fee in additional to our normal fees due at time of service.

I understand and agree to the above financial policy:
Patient or Parent/Guardian Name
Relationship
Signature

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Date

MonthDayYear
Date

Acknowledgement of Receipt of Notice of Privacy Practices
I acknowledge that I was provided (or had the opportunity to read if I chose) a copy of the Notice of Privacy practices and that I have read and understand the notice.
Patient Name
Parent or Authorized Representative (If applicable)
Signature

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Date

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Date

Patient Partnership Plan
Dear Patient:

Welcome to our practice. We intend to provide you with the care and service that you expect and deserve. Achieving you best possible health requires a “partnership” between you and your doctor. As our ‘partner in health” we ask you to help us in the following ways:

Keep Follow-up Appointments and Reschedule Missed Appointments
I understand that my doctor will want to know how my condition progresses after I leave the office. Returning to my doctor on time gives him the chance to check my condition and my response to treatment. During a followup appointment, my doctor might order tests, refer me to a specialist, prescribe medication, or even discover and treat a serious health condition. I will make every effort to reschedule missed appointments as soon as possible.

Call the Office When I Do Not Hear the Results of Lab and Other Tests
I understand that my physician’s goal is to report my lab and test results to me as soon as possible. However, if I do not hear from my physician’s office within the time specified, I will call the office for my test results.

Inform My Doctor If I Decide Not to Follow His or Her Recommended Treatment Plan
I understand that after examining me, my doctor may make certain recommendations based on what her feels is best for my health. This might include prescribing medication, referring me to a specialist, or ordering labs and tests, or even asking me to return to the office within a certain period of time. I understand that not following my treatment plan can have serious negative effects on my health. I will let my doctor know whenever I decide not to follow his or her recommendations so that he may fully inform me of any risks associated with my decision to delay or refuse treatment.

NOTIFICATON TO CONSUMERS

MEDICAL DOCTORS ARE LICENSED AND REGULATED BY THE
PODIATRIC MEDICAL BOARD OF CALIFORNIA
(800)633-2322
WWW.MBC.CA.GOV

Thank you for your partnership. As our patient, you have the right to be informed about your health care. We invite you, at any time, to ask questions, report symptoms, or discuss any concerns you may have. If you need more information about your health or condition, please ask.
Patient Signature

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Date

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Date
Should be Empty:

New Patient Form

Patient Information

Person Responsible for Payment

“Covered California” Patients

Financial Policy

Acknowledgement of Receipt of Notice of Privacy Practices

Patient Contact and Private Health Information (PHI)

Family to Facility Communication

Authorized Person(s)

Medical History

Current Medications

Surgical History

Allergies

Patient Partnership Plan