PATIENT INFORMATION

PATIENT INFORMATION
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone Number
Cell Phone Number
Email*
example@example.com
Birth date*
Age*
SS#
Gender

MaleFemaleOther
Marital Status
Spouse/Partner's Name

First NameLast Name
Spouse/Partner's Phone Number
Patient Occupation
Employed by
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone Number
Primary Insurance Carrier*
Member ID#*
Secondary Insurance Carrier
Member ID#
Primary Care Physician
Primary Physician Phone Number
Primary Care Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you come to choose Hollowbrook Foot Specialist, PC for your podiatric needs?*
Is there anyone we can thank for referring you?

WELCOME!

We would like to take this opportunity to welcome you to our practice and thank you for choosing our office to provide you with quality podiatric care. Please carefully read and sign the following below.

BILLING AND RETURNED CHECK FEES

You are responsible for payment at the time of service. If you don't pay that day, a billing fee of $15 will be charged to you.

Checks returned for non-payment (bounced checks) will incur a $30 charge.

CANCELLATION AND NO SHOW POLICY CHARGE

Every "no show" delays the opportunity for evaluation and treatment of other individuals. We ask you help us by giving 24 hours advanced notice of cancellation or rescheduling.

I understand that an appointment time has been made for me and if I do not keep my scheduled appointment, or if I do no give 24 hour advanced notice, I will be charged a $45.00 no show fee. I also understand that if the fee is not paid, it will be sent through the normal collection process.

If it becomes necessary for the account to be referred to an attorney for collection or suit, the undersigned shall pay reasonable attorney's fees and collection expenses. Further, I understand that coinsurance, unsatisfied deductible amounts, etc. are requested at time of service unless other financial arrangements have been made in advance.

Multiple cancellations and non-payment of no show fee will result in you being referred to a different medical practice.

I understand that New Patient Forms 1-4 must be fully completed, signed, and returned to Hollowbrook Foot Specialist, PC before my appointment.

REFERRALS

If your insurance requires a referral you are responsible for getting it before you are seen in our office. If you are seen and you did not get a referral you will be responsible for the charges incurred.

ASSIGNMENT OF BENEFITS

I hereby assign payment directly to Hollowbrook Foot Specialist, P.C., the insurance benefits otherwise payable to me. I understand that I am financially responsible for charges not covered by this authorization. I also authorize a photocopy of this as if it were an original copy.

I understand the above policies and agree to the terms.
Signature*

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Certain Waivers under HIPAA.

(a) Patient acknowledges that neither Group nor Physician guarantees that communications with Physician using electronic mail ("e-mail"), facsimile, video chat, instant messaging, and cellular telephone are secure or confidential methods of communications. Accordingly, Patient expressly waives Group’s and Physician’s obligations under the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. § 1320d et seq.), as amended by the Health Information Technology for Economic and Clinical Health Act of 2009, and all rules and regulations promulgated thereunder (collectively, "HIPAA"), and other state and federal laws and regulations applicable to the use, maintenance, and disclosure of patient-related information, to guarantee confidentiality with respect to correspondence using such means of communication. Patient acknowledges that all such communications may become a part of Patient’s medical records maintained by Physician.

(b) By providing Patient’s e-mail address to Physician, Patient authorizes Physician to communicate with Patient by e-mail regarding Patient’s "protected health information" ("PHI") (as defined under HIPAA) and Patient understands and agrees to the following:
1. E-mail is not necessarily a secure medium for sending or receiving PHI and, accordingly, any third party may gain access to such PHI;
2. Although Group and Physician will make all reasonable efforts to keep e-mail communications confidential and secure, neither Group nor Physician can assure or guarantee the absolute confidentiality of such e-mail communications.
Patient Initials:*
Patient acknowledges and agrees that Physician and Group, along with their assigns, will be entitled to use any data, discoveries, results, improvements or other information resulting from the Services for any lawful purpose whatsoever. All data will be kept on a Cloud Based system that is password protected, and accessible to Hollowbrook Foot Specialist, PC staff.
Patient Name*
Today's Date*

MonthDayYear
Patient Date of Birth*

MonthDayYear
Signature*

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HIPPA CONSENT FORM
I,*

First NameLast Name
Today's Date*

MonthDayYear
give my express permission to Dr. Yavor Geshev, to obtain and access to all of my medical records. I understand that my personal and medical information may be stored on a password protected secure cloud service.
Patient Date of Birth*

MonthDayYear
Any exceptions to medical record access:
Signature*

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I have been informed that Hollowbrook Foot Specialist, P.C. does NOT participate in no-fault or worker's compensation cases, and I confirm that the reson for my visit does NOT apply to either case. In the event my insurance denies claims indicating otherwise, I accept all financial responsibility for services rendered by my provider during my appointment.
Patient Name*
Today's Date*

MonthDayYear
Date
Signature*

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PATIENT INFORMATION

MEDICAL HISTORY

HIPPA CONSENT FORM