americanfootanklecenter.com - New Patient Form

Patient Demographic Information
Name:

First NameMiddle NameLast Name
Preferred Name:
Sex:

MaleFemale
DOB:

MonthDayYear
Date
Mobile Phone #:
Please enter a valid phone number.
Home Phone #:
Please enter a valid phone number.
Email Address:
example@example.com
Preferred method of communication

PhoneTextEmail
What language do you prefer?
Mailing Address:

Street Address

Apt # - Unit # - Lot #

CityState / Province

Postal / Zip Code
Current Insurance:
I understand due to the number of patients scheduled each day, patients are treated based upon appointment time not arrival time. I also understand if I am more than 15 minutes late, the appointment will have to be rescheduled.

I understand the information given will be entered in my chart and it is my responsibility to notify my doctor's office of any changes to the above information.

I hereby irrevocably assign to BC Medical Enterprises PLLC/American Foot & Ankle Centers LLC/Dr Brent Carter DPM any rights or benefits under the insurance policy listed above for any services and/or charges provided by them The insurance company is directed to send any payments to the provider listed in box 33 of the CMS 1500 form. As part of the Assignment of Benefits, i hereby direct the insurance carrier that in the event the medical benefits are disputed for any reason, including medical reasonableness and/or necessity, that the amount claimed by this provider are to be set aside and not disbursed until the dispute is resolved.
Signature

Clear
Date

MonthDayYear
Date

Pharmacy information
Name of pharmacy
Address of pharmacy
Phone number of pharmacy
Please enter a valid phone number.
I understand if I do not provide American Foot & Ankle Centers with the correct information regarding my pharmacy! will not receive any medication prescribed for me during and/or after my visit. I understand the prescriptions are sent electronically and it is my responsibility to give my doctor's office the correct information regarding my pharmacy and to update them if I change pharmacies. I understand if my prescription is sent to the wrong pharmacy due to incomplete or inaccurate information in my chart it may take much longer to get the prescription.
Primary Care Physician Information
Name of Doctor
Address of doctor's office
Phone number of doctor's office
Please enter a valid phone number.
Date you last saw this Primary Care Physician

MonthDayYear
Date
I understand it is my responsibility to provide the correct information regarding my PCP and if the office has the wrong information, it will delay treatment.

I certify the information given regarding my pharmacy and my PCP is correct and I will update the office of any changes.
Patient name:
Birth date:

MonthDayYear
Date
Signature:

Clear
Date:

MonthDayYear
Date

HIPAA Compliance Form
Our notice of Privacy Practices provides information about how we use or disclose protected health information.

This notice contains a patient's rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent form.

The terms of the notice may change and If so, you will be notified at your next visit to update your signature & date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do. we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected health Information. You have the right to revoke this consent in writing, signed by you. retroactive. However, such revocation will not be retroactive.

By signing this form I understand that:
- Protected health information may be disclosed or used for treatment, payment or healthcare operations.
- The practice reserves the right to change the privacy practices as allowed by law.
- The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
- The patient has the right to revoke consent in writing at any time and full disclosures will then
  cease.
- The practice may condition receipt of treatment upon execution of this consent.
May we phone, email or send a text to you to confirm appointments?

YesNo
May we leave a message on your answering machine at home or on your cell phone?

YesNo
May we discuss your medical condition with a family member or friend?

YesNo
IF YES..... please name the people allowed
Name of Patient
Signature

Clear
Date

MonthDayYear
Date
Witness
Date

MonthDayYear
Date

Consent to Treat Form
I (patient name) give permission for Brent Carter DPM/BC Medical Enterprises PLLC/American Foot & Ankle Centers to give me medical treatment.
I allow Brent Carter DPM/BC Medical Enterprises PLLC/American Foot & Ankle Centers to file for Insurance benefits to pay for the care I receive.

I understand that Brent Carter DPM/BC Medical Enterprises PLLC/American Foot & Ankle Centers will have to send my medical record Information to my insurance company.

I understand I must pay for my share of the costs.

I understand I must pay for the cost of these services if my Insurance does not pay or do not give the practice the correct Insurance Information. I also understand that if loo not have insurance at the time of treatment, I will have to pay the cost of the treatment.

I understand I have the right to refuse any procedure or treatment.
I understand I have the right to discuss all medical treatment with my clinician.
Patient signature

Clear
Date

MonthDayYear
Date
Parent/guardian signature

Clear
Date

MonthDayYear
Date
Witness signature

Clear
Date

MonthDayYear
Date
Print name
Date of birth

MonthDayYear
Date

American Foot & Ankle Centers
Brent Carter, DPM
24-hour Cancellations/No show appointments Policy

Effective Immediately

Due to an ongoing overwhelming number of last-minute cancellations and or no shows for scheduled appointments we are enforcing a policy effective immediately. We are noticing many of the same patients are chronically cancelling last minute or no showing to their scheduled appointments. We will allow ONLY 1 missed appointment or last- minute cancellation that we will log and have a record of.

For any cancellations made less than 24 hours prior to your scheduled appointment or any no show appointment a $75.00 fee will be enforced. This fee must be paid prior to rescheduling or being seen in the office. Continued last minute cancellations and no shows will result in continued fees enforced and or termination from this practice.

In addition, we do our best to reach out to remind patients of their appointment date and time, however it is the patient responsibility to remember their scheduled appointment date and time.

This is to acknowledge the enforcement of this policy.
Patient name
Date

MonthDayYear
Date
Should be Empty:

Patient Demographic Information

MEDICAL:

ALLERGIES:

Please select all that apply

SOCIAL HISTORY

Pharmacy information

Primary Care Physician Information

HIPAA Compliance Form

Consent to Treat Form