dallasfoot.com - New Patient Form

REFERRAL POLICY
If your insurance is a part of Managed Care plan (HMO, POS, EPO, etc.), failure to obtain a valid referral from your primary care physician (PCP) may result in reduced or no benefits being paid.

Non-Covered Foot Care
Your insurance carrier may determine that your foot care is an excluded service, in which case no reimbursement will be made. Should this occur, the responsibility of payment will remain yours as the recipient of these services. (This includes orthotics, splints, over the counter medications, heel cups, pads, and toe separators, i.e., anything that is given to you in this office that your carrier may not pay).

Consent to Treat and Financial Responsibility
I hereby authorize Metroplex Foot and Ankle, LLP to render medical services and care to the patient indicated below. The duration of this consent is indefinite and continues until revoked in writing. I understand that by not signing this consent, the patient will not be provided medical care except in case of emergency.
Patient Name
Signature of Patient, Parent, or Legal Guardian
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Payment is expected at the time of your visit. We accept cash, check or credit cards. As our patient you are responsible for all payments of any deductible, co-insurance, co-pay or non-covered services. Your insurance policy is a contract between you and your insurance company. As a courtesy, we will file your insurance claim for you. As our patient you are responsible for any unpaid bills 60 days after insurance is filed. If for any reason the account becomes delinquent, I agree to pay for all collection and legal fees. I authorize Metroplex Foot and Ankle, L.L.P. to release medical information pertinent to filing of an insurance claim for me. There is a service fee of $25 for all returned checks. I understand that Metroplex Foot and Ankle Physicians may have financial interests in North Garland Surgery Center, Breckenridge Surgery Center, Millennium Pharmaceuticals and Health Scripts Pharmacy.
Patient Name
Signature of Patient, Parent, or Legal Guardian
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ACKNOWLEDEMENT OF RECEIPT OF PRIVACY NOTICE

We are required by law to provide you with a copy of our Notice of Privacy Practices. To ensure that our records are accurate, please sign this form to acknowledge that you have been provided with a copy of our notice.

To the best of my knowledge, I have answered the questions on this form accurately. I understand that providing incorrect information can be dangerous to my health. I understand that it is my responsibility to inform the doctor and office staff of any changes in my medical status.
Patient Name
Signature of Patient, Parent, or Legal Guardian
Date

MonthDayYear
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REQUEST FOR CONFIDENTIAL COMMUNICATIONS
NAME OF PATIENT:
DATE OF BIRTH:

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I REQUEST THAT ALL COMMUNICATIONS TO ME (BY PHONE, MAIL OR OTHERWISE) BY METROPLEX FOOT AND ANKLE, LLP PHYSICIANS AND STAFF BE HANDLED IN THE FOLLOWING MANNER:
FOR WRITTEN COMMUNICATIONS OTHER THAN HOME ADDRESS:
FOR VERBAL COMMUNICATIONS CALL:
MAY WE LEAVE A MESSAGE?

YESNO
USE OF ELECTRONIC COMMUNICATIONS FROM METROPLEX FOOT AND ANKLE, LLP TO PATIENT
METROPLEX FOOT AND ANKLE, LLP OFFERS YOU A CONVENIENCE TO COMMUNICATE ELECTRONICALLY WITH YOU UNDER THE CONDITIONS AND TERMS OUTLINED BELOW. IF USING YOUR WORK EMAIL ADDRESS, PLEASE CONSIDER THE PRIVACY IMPLICATIONS THAT YOUR EMPLOYER MAY HAVE THE RIGHT AND/OR ABILITY TO REVIEW ALL EMAIL RECEIVED AT YOUR WORK ADDRESS.

YES, I want Metroplex Foot and Ankle, LLP to communicate with me electronically.No, I do not want Metroplex Foot and Ankle, LLP to use electronic communications as a way of communicating my information to me.
EMAIL
example@example.com
METROPLEX FOOT AND ANKLE, LLP EMAIL GUIDELINES
1. THE PATIENT IS RESPONSIBLE TO NOTIFY METROPLEX FOOT AND ANKLE PROMPTLY OF ANY CHANGES TO HIS/HER EMAIL ADDRESS.
2. ALL ELECTRONIC COMMUNICATIONS ARE CONSIDERED A PART OF YOUR MEDICAL RECORDS AND ARE RECORDED. THOSE WHO HAVE ACCESS TO YOUR MEDICAL RECORD ALSO HAVE ACCESS TO THE EMAIL MESSAGES SENT TO YOU.
3. METROPLEX FOOT AND ANKLE WILL NOT SHARE YOUR EMAIL ADDRESS WITH ANYONE UNAUTHORIZED TO VIEW YOUR MEDICAL RECORD.
CONSENT AND AGREEMENT

I HAVE CAREFULLY REVIEWED THIS DOCUMENT AND AGREE TO FULLY COMPLY WITH THE GUIDELINES DEFINED HEREIN FOR ELECTRONIC COMMUNICATION FROM METROPLEX FOOT AND ANKLE. I UNDERSTAND THAT THIS SERVICE WILL BE OFFERED AT NO CHARGE.
Patient Name
Signature of Patient, Parent or Legal Guardian
Date

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MISSEDAND LATE APPOINTMENT POLICY
Cancellation Policy:

To notify patients of a financial penalty for failure to cancel a scheduled appointment our office will document in the electronic medical record when a patient no shows for an appointment or cancels an appointment on short notice.

Failure to give 24 hour notice of cancellation of an appointment or no-showing for an appointment will result in a charge of $50.00 to the patient's account. This charge cannot be billed to the insurance company. Medical care will not be withheld for a medical emergency. All fees must be paid before a new appointment can be scheduled. After (3) missed appointments, the practice may at its discretion choose to discontinue your care.

Late Arrival Policy:

Please note that if you are 10 minutes late for your scheduled appointment you may be asked to reschedule.

Procedure:
CHECK ONE BOX. SIGN & DATE BELOW.

YES. I understand the Missed and Late Appointment: I have been informed that a $50 charge will be applied to my account when I miss appointments without giving proper notice. I understand that this charge cannot be billed to an insurance company. I agree to be personally and fully responsible for payment.NO. I have decided not to receive services.
Patient Name
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Signature of Patient, Person or Legal Guardian