stellarfoot.com - New Patient Form

Financial Policy
The Doctor and Staff would like to welcome you to our practice. We will strive to provide you with excellent medical care and our goal is to make your visits as pleasant as possible. By signing below, you confirm that you have read this policy and understand that:
- It is your responsibility to inform our office of any address or telephone number changes.
- Our billing service sends statements on all accounts with an outstanding balance to the address we have on the account.
- Your account is to be kept current accordingly, all self-pay, or insurance co-payments, co insurance deductibles will be collected at the time of the service.
- Payments can be made by cash, check, Visa, Mastercard, or Discover.
- We reserve the right to charge $20.00 for appointment cancelled or broken without 24 hours' noctie.
If you have health Insurance Coverage:
We will submit your claims, however, we must emphasize that as medical providers,

OUR RELATIONSHIP IS WITH YOU, NOT YOUR INSURANCE COMPANY
By signing below, you confirm and understand:
- It is your responsibility to inform us of any changes to your insurance policy so that your coverage can re-verified prior to your appointment.
- Not all services are covered benefits with insurance plans.
- It is your responsibility to be aware of what service(s) is being provided to you and if it is a covered benefit under your insurance policy.
- You are responsible for any non-covered charges not payable by your insurance policy.
- We do not file third party insurance companies only primary and secondary.
- Although filing your insurance claims is a courtesy extended to you, all charges are always your responsibility from the date services are rendered.
I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize, Dr. Rowan to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions.
Patient Signature

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Responsible Party Signature

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Date

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Acknowledge of Receipt of Notice of Privacy Practices
I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read (or had the opportunity to read if I so choose) and understand the Notice.
Patient Name
Patient Signature

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HIPAA Disclose Form
Patient Name:
DOB:

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Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.
I, Name Hereby authorize Dr. Rowan to release my medical information
(appointments, labs/x-ray results, diagnosis, treatments, medications, surgeries, etc) via postal mail, telephone, fax, or email to the following family members:
Patient Signature:

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Date:

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	Yes	No
1. Do you experience any pain on your legs or feet while at rest?
2. Do you have uncomfortable aching, fatigue, tingling, cramping, or pain your feet, calves, buttocks, hip or thigh during exercising?
3. If yes to ques on 2, does this pain go away when you stop walking/exercising?
4. Do your feet get pale, discolored or bluish at any me of the day?
5. Do you have an infection, skin wound or ulcer on your leg or foot that is slow to heal over the past 8 to 12 weeks?
6. Are you 65 years of age or older?
7. Are you 50 years of age or older?
8. Do you have high cholesterol or other blood lipid (fat) problems that require cholesterol medica on?
9. Do you have high blood pressure or take medica on to reduce blook pressure?
10. Do you have diabetes?
11. Do you have history of chronic kidney disease?
12. Do you currently or have you ever smoked?
13. Do you have history of stroke or mini stroke (TIA)?
14. Do you have a history of heart disease (heart a ack, MI)?
15. Do you have a history of carotid stenosis, abdominal aortic aneurysm (AAA), and/or stent placement?

New Patient Form

Patient Information:

Additional Medical

Social History (over 12 years old)

Vaccination Status:

Advanced Care (over 65 years of age)

Financial Policy

Acknowledge of Receipt of Notice of Privacy Practices

HIPAA Disclose Form

Vascular Disease Survey