Victoria Foot & Ankle Center – New Patient Intake
  • Patient Demographics

    Please have your photo ID and insurance cards ready before starting.
  • Date of Birth*
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  • Sex Assigned at Birth*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
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  • Insurance Information

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  • Is policyholder the patient?
  • Primary Policyholder Date of Birth
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  • Do you have secondary insurance?
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  • Is policyholder the patient?
  • Secondary Policyholder Date of Birth
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  • Medical History

  • Conditions*
  • Allergies*
  • Medications

  • How would you like to enter your medications?
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  • Visit Information

  • How does this problem impact your daily activities?
  • Notice of Privacy Practices (HIPAA)

  • This Notice of Privacy Practices describes how your medical information may be used and disclosed by our clinic and outlines your rights regarding access to and control of that information. Please review this document carefully, as it contains important information about how we safeguard your privacy in compliance with the Health Insurance Portability and Accountability Act (HIPAA) and applicable laws of the State of Texas.

     Our Commitment to Your Privacy

    Victoria Foot and Ankle Center is committed to maintaining the confidentiality, integrity, and security of your Protected Health Information (PHI). We implement comprehensive administrative, physical, and technical safeguards designed to protect your information from unauthorized access, disclosure, alteration, or destruction. Our staff receives ongoing training on privacy practices, and we routinely review our systems and procedures to ensure continued compliance with federal and state regulations.

    How We Use and Disclose Your Information

    Treatment: We may use and share your health information to provide, coordinate, and manage your medical care, including communication with physicians, specialists, pharmacies, laboratories, imaging centers, and other healthcare providers involved in your treatment. Payment: We may use your information to bill for services and collect payment from you, your insurance provider, or other responsible parties. This may include sharing information necessary to determine eligibility, coverage, and medical necessity. Healthcare Operations: We may use your information to support the overall operation of our practice, including quality assessment, performance improvement, staff training, compliance monitoring, credentialing, and general administrative functions.

    Use of Technology

    To enhance the quality, efficiency, and accuracy of the care we provide, our clinic may utilize advanced technologies, including artificial intelligence systems, as part of our clinical and administrative workflows. These technologies may assist with medical documentation, organization of clinical data, communication, and operational processes. The artificial intelligence-assisted tools may be used for tasks such as generating draft clinical notes, summarizing visit information, supporting coding workflows, and improving internal efficiency. However, all outputs generated by such systems are carefully reviewed, verified, and finalized by a licensed healthcare provider prior to being included in your official medical record. We take extensive precautions to ensure that any technology used complies fully with HIPAA requirements and applicable privacy laws. Your information is encrypted, securely processed, and accessed only by authorized personnel. These technologies are used strictly as supportive tools and do not replace clinical judgment, diagnosis, or decision-making by your provider. We do not sell your health information, and we do not permit unauthorized third parties to access or use your data for marketing or unrelated purposes.

    Your Rights Regarding Your Information

    You have important rights regarding your health information. These include the right to access and obtain copies of your medical records; request amendments if you believe information is inaccurate or incomplete; request restrictions on certain uses or disclosures; request confidential communications through alternative methods or locations; and obtain an accounting of certain disclosures of your information. You also have the right to file a complaint if you believe your privacy rights have been violated. You may do so without fear of retaliation.

    Our Responsibilities

    We are required by law to maintain the privacy and security of your Protected Health Information, provide you with this notice of our legal duties and privacy practices, and notify you promptly in the event of a breach that may compromise your information. We are also required to follow the terms of this notice as currently in effect.

    Special Situations

    We may disclose your information when required or permitted by law. This includes disclosures for public health activities, reporting of certain conditions, law enforcement purposes, workers’ compensation claims, and health oversight activities conducted by authorized agencies.

    Changes to This Notice

    We reserve the right to modify or update this Notice of Privacy Practices at any time. Any changes will apply to all information we maintain and will be made available in our office and upon request. You may also file a complaint with the U.S. Department of Health and Human Services.

  • Consents

  • Consent to Treatment

    I voluntarily consent to the medical care and treatment provided by the physicians, providers, and staff of Victoria Foot & Ankle Center. I understand that medical care may include examinations, diagnostic testing, procedures, treatments, and other services deemed medically necessary by my provider.

    Assignment of Benefits & Financial Responsibility

    I authorize payment of medical insurance benefits directly to Victoria Foot & Ankle Center for services rendered. I understand that I am financially responsible for all charges not paid by my insurance company, including copayments, deductibles, coinsurance, non-covered services, and any remaining balances after insurance processing. I agree to pay such amounts in accordance with the practice's financial policies.

    HIPAA Acknowledgment

    I acknowledge that Victoria Foot & Ankle Center maintains a Notice of Privacy Practices describing how my protected health information may be used and disclosed. I understand that I may request a copy of the Notice of Privacy Practices at any time.

    Communication Authorization

    I authorize Victoria Foot & Ankle Center to contact me regarding appointments, treatment, prescriptions, referrals, billing matters, and other healthcare-related communications using the contact information I have provided.

    I understand communications may be sent by telephone call, voicemail, text message, email, or patient portal message. Standard message and data rates may apply. I understand that the information sent to me via email and/or text message from persons at Victoria Foot and Ankle Center may not be sent securely and will be unencrypted. I understand the risks associated with that including, but not limited to, my PHI may be read by an unintended third party.

    Assisted Documentation

    I understand that Victoria Foot & Ankle Center may use secure artificial intelligence technology to assist with documenting medical visits. I understand that conversations during my visit may be processed by artificial intelligence software solely for the purpose of generating clinical documentation. My healthcare provider reviews, edits, and approves all documentation before it becomes part of my medical record. I understand that the use of artificial intelligence assisted documentation is subject to applicable privacy and security requirements, including HIPAA.

    Acknowledgment

    I certify that the information I provide to Victoria Foot & Ankle Center is true and accurate to the best of my knowledge. I have read and understand the above information and voluntarily agree to these terms.

  • Date
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