LAUREL Patient Registration form

8320 OLD COURTHOUSE RD| SUITE 304 | VIENNA, VA 22182
Name*

First NameLast Name
D.O.B

MonthDayYear
Date
M.I
SSN
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Please enter a valid phone number.
Home Phone

Area CodePhone Number
Email
example@example.com
Marital Status

MarriedSingleWidowSeparatedDivorced
Spouse's Name
Financially Responsible Person, If Different From Patient
Cell Phone
Please enter a valid phone number.
Work 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
Policy ID #
Group #
Secondary Ins. Co.
Name of Policy Holder
Relationship
Policy Holder's DOB

MonthDayYear
Date
Policy ID #
Group #
Policy Holder's Employer
Policy Holder's Employer

Area CodePhone Number
MEDICARE LIFETIME SIGNATURE ON FILE
I request that payment of authorized Medicare benefits be made either to me or on my behalf to Northern Virginia Foot and Ankle Associates/Laurel Foot and Ankle Center for any services furnished to me by the physician. 1 authorize any medical information about me to be released to the Health Care Financing Administration and any agent information needed to determine these benefits or benefits payable for related services.
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 covered 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*
Anemia*
Arthritis*
Artificial Heart Valve/Joints*
Asthma*
Back Problems*
Bleeding Disorder*
Cancer*
Chemical Dependency*
Chest Pain*
Circulatory Problems*
Diabetes*
Epilepsy*
Eye Problems*
Gout*
Headaches*
Heart Disease*
High Blood Pressure*
Kidney Problems*
Liver Disease*
Low Blood Pressure*
Nervous Problems*
Psychiatric Care*
Respiratory Disease*
Rheumatic Fever*
Shortness of Breath*
Sinus Problems*
Stroke*
Tuberculosis*
Ulcers*
Varicose Veins*
Weight Loss, Unexplained*
Other Past Medical History
Have you had any surgery? If yes, please list all past surgeries
Date

MonthDayYear
Date
Have you had any surgery? If yes, please list all past surgeries
Date

MonthDayYear
Date
Have you had any surgery? If yes, please list all past surgeries
Date

MonthDayYear
Date
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 (circle)

Drink Alcohol?Smoke Tobacco?
If yes, how much?
Do you experience abnormal bleeding with surgery, cuts, extractions, or trauma?*
Are you, or is there any chance you may be pregnant?*
Put a check by any conditions below that any blood relatives have or had
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 that 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 HAVE READ ALL POLICIES.
blanksCOPAYMENTS: 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.
blanksDEDUCTIBLES 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.
blanksSELF-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 off regular fees is offered for payment made at time of service.
blanksREFERRALS: 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.
blanksRETURNED 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.
blanksFORMS/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.
blanksDMV HANDICAP PARKING APPLICATIONS: There is a $10.00 fee for ALL DMV handicap parking applications.
blanksNO 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 for your scheduled appointment.
blanksSURGERY CANCELATION FEE: Any surgeries cancelled 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)
Service charges are assessed for all accounts 30 days past due. Failure to pay outstanding balance promptly will result in actions being taken with our outside collection agency to achieve collection of fees. The patient is directly responsible for any laboratory expenses. Please sign below to acknowledge that you have read and understand our Policy of Payment Agreement for Medical Services and Products
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.
Signed

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Date

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

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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
***If a doctor did not refer you to our practice, please check an option below:
A friend who is a current patient
Magazine article or advertisement
Insurance Carrier:
Google/Internet SearchFacebookYelp!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:
Cell #
Please enter a valid phone number.
E-mail
example@example.com
Regarding the following

1. Appointment Reminders/Changes Account2. Payments/Balances3. Cost Estimates4. Needed Treatment/Completed Treatment
Printed Name
Signature

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Date

MonthDayYear
Date
Should be Empty:

Insurance Coverage

MEDICARE LIFETIME SIGNATURE ON FILE

PRIVATE INSURANCE AUTHORIZATION FOR ASSIGNMENT OF BENEFITS AND INFORMATION RELEASE

MEDICAL HISTORY

Other Past Medical History

Policy for Payment of Medical Services and Products Agreement

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

How did you hear about us?

CONSENT TO LEAVE MESSAGES

Consent for Leaving Messages

Regarding the following