acclaimfootandankle.com

Insurance: Assignment and Release
I, the undersigned certify that I (or my dependent) have insurance coverage with Name and assign directly to Dr. Corcoran all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
Print Name
Patient/ Responsible Party Signature

Clear
Relationship
Date

MonthDayYear
Date
Medicare Authorization:

I request that payment of authorized Medicare benefits be made either to me or on my behalf to Dr. Corcoran for any services furnished me by Dr. Corcoran. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If "other health insurance" is indicated in item 9 of the HCFA 1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and non covered services. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier.
Beneficiary Signature:

Clear
Date:

MonthDayYear
Date
Patient Financial Policy Notice:
Responsible Party Name
DOB

MonthDayYear
Date
SS#
Relationship to Patient
Our office is currently utilizing an outside billing service. As a courtesy to you, we will bill your insurance carrier(s) for any services rendered.

Be it understood that insurance does not pay for all services rendered or medical equipment dispensed. I understand that I am ultimately responsible for the balance on my account for any professional services rendered. I further agree to give notice of any changes in insurance coverage and health status in a timely manner to avoid any delay in billing. I agree that after insurance determination on any claim has been made and upon receipt of a statement of patient balance due responsibility. I will make prompt payment to the office — within 10 days. Any balance which is not paid will be considered past due. In the event I make it necessary for Acclaim Foot and Ankle Center, P.C. to turn my account over for collections, I understand that I will be responsible for any and all collections fees as well. I sign below to acknowledge my understanding and willingness to comply with this Patient Financial Policy Notice.
Patient/ Responsible Party Signature

Clear
Date

MonthDayYear
Date

Authorization for Release of Medical Records and/or Information
I authorize the release of photocopies of the following medical records and/or Xray films in the possession of Acclaim Foot and Ankle Center, P.C., it's employees and/or agents. For the purpose hereof, "Medical Records and X-Ray Films" shall include all confidential HIV related information (as defined in A.R.S. Section 36-661) Confidential Communicable Disease related information as defined in (R.R.S. Section 36-3661), Confidential alcohol or drug abuse related information as defined in 42 (FR Section 2.1 ET SEQ), and confidential mental health diagnosis/treatment information.

I authorize Acclaim Foot and Ankle Center, P.C., to release medical information and/or discuss all matters related to my treatment and/or care to the entities indicated below. I understand that confidentiality cannot be guaranteed.
Primary Care Physician:
Other Physicians:

Family and/or other persons: (please list names and relationship)

	Name	Relationship
1
2
3

I Authorize Acclaim Foot and Ankle Center, P.C., to leave results or detailed messages on the below number.
Phone Number:
Please enter a valid phone number.
Hours
Patient Signature:

Clear
Date

MonthDayYear
Date

Patient Information
Name

First NameInitialLast Name
DOB

MonthDayYear
Date
SS#
Address
Marital Status:
Gender:
Race:
Ethnicity:
Your Approved Methods For Communication:
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Email
example@example.com
Best method to reach you?
Occupation:
Employer:
Email Address
example@example.com
Emergency Contact Name:
Cell Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Relationship to Patient:
Insurance Information
Primary Insurance:
Policy#:
Group/Network
Policy Holder
DOB

MonthDayYear
Date
Relationship to Patient
Claims-Billing Address:
Phone Number
Please enter a valid phone number.
Secondary Insurance:
Policy#:
Group/Network
Policy Holder
DOB

MonthDayYear
Date
Relationship to Patient
Claims-Billing Address:
Phone Number
Please enter a valid phone number.
Guarantor Information:

Person financially responsible for patient's account
Name

First NameLast Name
DOB

MonthDayYear
Date
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How were you referred?

PhysicianFamilyFriendInternet
Physician Name
Patient/Guardian Signature:

Clear
Date

MonthDayYear
Date
Should be Empty:

	C	P
AIDS/HIV
Allergy to Anesthetic
Anemia
Angina
Arthritis
Artificial Valves/Joints
Asthma
Back Issues
Bleeding Disorder
Cancer
Chemical Abuse
Chest Pain
Circulatory Issues
COPD
Seizures
Valley Fever
Diabetes
Hearing Loss
Eye Issues
Fainting
Foot/Leg Cramps
Gout
Headaches
Heart Disease
Hemophilia
Hepatitis
High Blood Pres.
Kidney Problems
Lupus
Nervous Issues
Phlebitis
Thyroid Disease
Valley Fever
Psychiatric Care
Radiation Therapy
Rash
Respiratory Disease
Rheumatic Fever
Shortness of Breath
Sinus Problems
Stroke
Swelling Ankles/Feet
Swollen Glands
Tuberculosis
Ulcers
Varicose Veins
Venereal Disease
Sleep Apnea
Weight Loss
Unexplained

Insurance: Assignment and Release

Patient Financial Policy Notice:

Reason For Visit

Medical History

Current Medications

Social History:

Patient Information

Insurance Information

Guarantor Information: