• PATIENT INFORMATION

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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • RESPONSIBLE PARTY

  • Format: (000) 000-0000.

  • INSURANCE INFORMATION

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  • PATIENT INTAKE

    Please complete all sections to the best of your ability. Our staff is here to help with any questions you may have.
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  • Format: (000) 000-0000.

  • Reason for Visit

  • Pain Assessment

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  • ALLERGIES

  • MEDICAL HISTORY

  • For Diabetic Patients Only

  • MEDICATIONS

  • Rows

  • SURGICAL HISTORY

  • Rows

  • SOCIAL HISTORY

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  • FAMILY HISTORY

  • Rows
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  • REVIEW OF SYSTEMS

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  • ACKNOWLEDGEMENT AND CONSENT TO TREAT

  • Consent for Treatment:

    I consent to any treatments or procedures that may be performed on an outpatient basis, including emergency treatments and services. This may encompass, but is not limited to, medications, injections, medical photography, laboratory tests, and X-ray examinations. I understand that these services will be provided according to the general and specific instructions of Dr. Aree Saeed, the staff, and other healthcare providers at Podiatry Care Plus who are involved in my care.

    I certify that the information above is true and correct to the best of my knowledge. I have been informed that if I am uncertain about any question on the form, I should ask the doctor or a member of the office staff for assistance. By signing below, I hereby authorize Podiatry Care Plus, LLC to obtain medication history from community pharmacies and/or pharmacy benefit managers for the purpose of ongoing treatment.

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  • SUMMARY NOTICE OF PRIVACY PRACTICES

  • The Notice of Privacy Practices contains a detailed description of how our office will protect your health information, your rights as a patient, and our common practices in dealing with patient health information.

    Uses and Disclosures of Health Information:

    We will use and disclose your health information in order to treat you or to assist other health care providers in treating you. We will also use and disclose your health information to obtain payment for our services or to allow insurance companies to process claims for services rendered to you by us or other health care providers. Finally, we may disclose your health information for certain limited operational activities such as quality assessment, licensing, accreditation, and training of students.

    Uses and Disclosures Based on Your Authorization:

    Except as stated in more detail in the Notice of Privacy Practices, we will not use or disclose your health information without your written authorization for:

    • Family members or close friends who are involved in your health care.
    • Certain limited research purposes.
    • Public health and safety.
    • Government agencies for audits, investigations, and other oversight activities.
    • Authorities to prevent child abuse or domestic violence.
    • The FDA to report product defects or incidents.
    • Law enforcement to protect public safety or to assist in apprehending criminal offenders.
    • Court orders, search warrants, subpoenas, and as otherwise required by law.

    Patient Rights:

    As our patient, you have the following rights:

    • To have access to and/or a copy of your health information.
    • To receive an accounting of certain disclosures we have made of your health information.
    • To request restrictions on how your health information is used or disclosed.
    • To request that we communicate with you in confidence.
    • To request that we amend your health information.
    • To receive notice of our privacy practices.

    If you have questions, concerns, or complaints regarding our privacy practices, please contact our office at 240-295-0405.

  • I,      (name of patient), acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read or had the opportunity to read, and understood the Notice. By signing below, I hereby authorize Dr. Aree Saed, Podiatry Care Plus, LLC, to obtain medication history related to the patient above from Community Pharmacies and/or Pharmacy Benefit Managers for the purpose of continued treatment. 

    In addition, I authorize the following      individuals’ access to my personal health information upon request.   

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  • FINANCIAL POLICY

  • Payment in Full:

    Payment in full is due at the time of service unless prior arrangements have been made.

    Co-Payments:

    Office visit co-payments for our participating HMO/PPO insurances are due at the time of service. For insurance plans with deductibles and co-insurance obligations, applicable amounts due for services rendered are also required at the time of service.

    Claim Filing:

    If we are a participating provider with your primary health insurance, we are happy to file a claim on your behalf. However, once the insurance company is billed, we allow 60 days for the balance to be paid by your insurance carrier. If the insurance company does not remit payment within 60 days, the balance will be due in full of you. If any payment is subsequently made by your insurance carrier in excess of the balance, we will gladly issue a refund for the overpayment to you within 30 days, provided that you do not have any outstanding accounts with our office.

    Patient Responsibility:

    An HMO/PPO claim denial due to no referral or authorization is the patient's responsibility. Our office staff will notify and assist you with referral and pre-certification procedures, but the final responsibility lies with the patient to comply with their specific insurance requirements. All referrals must be presented to our office before seeing the doctor.

    Insurance Card:

    Please present your most recent insurance card each time you visit if we participate with your plan to ensure proper filing of information for claims submission. Otherwise, your visit may not be covered, and you will be responsible for payment. A $15 service fee will be assessed for re-filing insurance claims due to incomplete or incorrect information provided at the time of the appointment.

    Returned Checks:

    There is a $25.00 fee for all returned checks.

    Unpaid Balances:

    All unpaid balances are subject to a 1.5% interest charge after 30 days. For balances that remain unpaid after 90 days, we will take appropriate collection actions, including registering the amount past due with the EQUIFAX credit rating service. If your account must be forwarded to a collection service and/or attorney due to non-payment, you will be responsible for all collection and/or attorney fees charged by these services.

    Missed Appointments:

    Please be on time for your appointment. Podiatry Care Plus, LLC reserves the right to charge a fee of $50.00 for all missed appointments ("no shows") and for appointments that are not canceled with a compelling reason at least 24 hours in advance. "No show" fees will be billed to the patient. This fee is not covered by insurance and must be paid prior to your next appointment. Multiple "no shows" in any 12-month period may result in termination from our practice. If you are 15 minutes late or more for your appointment, you may be asked to reschedule.

    Outpatient Surgery:

    If you are scheduled for outpatient surgery, there will be a $150.00 fee for rescheduling or canceling the surgery.

  • ASSIGNMENT OF BENEFITS

  • I understand and certify that I (or my dependent) have coverage with      and assign directly to Podiatry Care Plus, LLC all insurance benefits payable to me for services rendered. I understand that I am responsible for payment of my deductibles, co-payments, and/or non-covered services. I hereby authorize the doctor to release all information necessary to secure payment of benefits. I authorize the release of medical information to my insurance carrier or requested physician to provide continuity of care. I authorize the use of this signature on all insurance submissions. By my signature, I acknowledge receipt of a copy of this policy and hereby agree to its terms.

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