• Chambers Foot & Ankle

  • Patient Information

  • Today's Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex:
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Responsible Party Information(If self leave blank)

  • DOB:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Chambers Foot and Ankle - 7525 East Broadway Road, Suite 10 - Mesa, AZ 85208
    Phone (480) 985-3730 - Fax (480) 985-4532
  • Date of Birth:
     - -
    2 digit month, 2 digit day, 4 digit year

  • ASSIGNMENT OF BENEFITS

  • I authorize the release of information necessary to process this claim and hereby assign my insurance benefits be paid directly to Thomas J. Chambers DPM, and Chambers Foot and Ankle LLC. I acknowledge financial responsibility for services, which are not covered by my insurance company.
  • Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • I authorize Chambers Foot and Ankle LLC to send me appointment reminders to:
  • Format: (000) 000-0000.
  • Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Chambers Foot and Ankle - 7525 East Broadway Road, Suite 10 - Mesa, AZ 85208
    Phone (480) 985-3730 - Fax (480) 985-4532
  • Date of Birth:
     - -
    2 digit month, 2 digit day, 4 digit year

  • Podiatric History

  • Chief Complaint (Circle and fill in the blank)

  • Did your pain come on suddenly or gradually?
  • Was there an injury?
  • Is your pain getting: Better, Worse, or Staying the Same
  • Rate your pain: (no pain) 0 2 3 4 5 6 7 8 9 10 (extreme pain)

  • Review of Systems

  • (Circle all that apply)

  • Constitutional:
  • Cardiovascular:
  • Skin:
  • Neurological:
  • Musculoskeletal:
  • Chambers Foot and Ankle - 7525 East Broadway Road, Suite 10 - Mesa, AZ 85208
    Phone (480) 985-3730 - Fax (480) 985-4532
  • Date of Birth:
     - -
    2 digit month, 2 digit day, 4 digit year

  • Medical History (Circle all that apply)

  • Medical History Options

  • Social History (Circle or fill in the blank)

  • Tobacco:
  • Alcohol:
  • Chambers Foot and Ankle - 7525 East Broadway Road, Suite 10 - Mesa, AZ 85208
    Phone (480) 985-3730 - Fax (480) 985-4532
  • Date of Birth:
     - -
    2 digit month, 2 digit day, 4 digit year

  • Chambers Foot and Ankle - 7525 East Broadway Road, Suite 10 - Mesa, AZ 85208
    Phone (480) 985-3730 - Fax (480) 985-4532

  • Date of Birth:
     - -
    2 digit month, 2 digit day, 4 digit year
  • I authorize the release of medical information / test results to the following person(s) other than myself.
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • I authorize Chambers Foot and Ankle LLC to leave information / test results on my voicemail and / or answering machine at the following contact numbers.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Chambers Foot and Ankle - 7525 East Broadway Road, Suite 10 - Mesa, AZ 85208
    Phone (480) 985-3730 - Fax (480) 985-4532
  • Date of Birth:
     - -
    2 digit month, 2 digit day, 4 digit year

  • ACKNOWLEDGEMENT 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 chose) and understood the Notice. (Ask front desk for copy)
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • PATIENT FINANCIAL OBLIGATION AGREEMENT

    • I / WE, THE UNDERSIGNED, AUTHORIZE THE DOCTOR(S) AND STAFF OF THE MEDICAL PRACTICE LISTED ABOVE TO TREAT THE PATIENT NAMED ON THIS FORM AND AGREE TO PAY ALL FEES AND CHARGES FOR SUCH TREATMENT.
    • I / WE AGREE TO PAY ALL CHARGES FOR MYSELF AND MEMBERS OF MY FAMILY PER THE TERMS OF THIS AGREEMENT. CHARGES SHOWN ON THE BILLING STATEMENTS ARE AGREED TO BE CORRECT AND REASONABLE UNLESS DISPUTED IN WRITING WITHIN 30 DAYS OF THE BILLING DATE.
    • I / WE ACKNOWLEDGE THAT SHOULD ANY BALANCE REMAIN UNPAID BY MY HEALTHCARE PLAN AFTER 90 DAYS FROM THE DATE THAT SERVICES WERE PROVIDED, THE ENTIRE BALANCE WILL BE BILLED TO ME. IF ANY PATIENT BALANCE IS NOT PAID IN FULL WITHIN 30 DAYS OF THE ORIGINAL PATIENT STATEMENT DATE, THE ENTIRE BALANCE WILL BE SUBJECT TO A 1.5% MONTHLY SERVICE CHARGE.
    • I / WE AGREE THAT IN THE EVENT THAT LEGAL ACTION BECOMES NECESSARY TO COLLECT AN UNPAID BALANCE DUE FOR SERVICES RENDERED TO ME OR MY LEGAL CHARGE, I AM RESPONSIBLE FOR ANY AND ALL ATTORNEY'S FEES AND COURT COSTS INCURRED BY THE ABOVE MENTIONED MEDICAL PRACTICE OR ITS' REPRESENTATIVES.
    • I / WE AGREE THAT PAYMENTS WILL NOT BE DELAYED OR WITHHELD, REGARDLESS OF TREATMENT OUTCOME, LAWSUITS, LIENS, OR INSURANCE COVERAGE OR THE PENDENCY OF CLAIMS THEREON. IT IS ALSO AGREED THAT ALL PROCEEDS OF INSURANCE OR MEDICAL BENEFITS PROGRAM(S) ARE ASSIGNED TO THIS MEDICAL PRACTICE WHERE APPLICABLE. I / WE UNDERSTAND THAT I AM RESPONSIBLE FOR PAYING ALL DEDUCTIBLES, CO-PAYMENTS, NON-COVERED SERVICES, AND ANY PORTION OF COVERED SERVICES
  • Chambers Foot and Ankle - 7525 East Broadway Road, Suite 10 - Mesa, AZ 85208
    Phone (480) 985-3730 - Fax (480) 985-4532
  • Date of Birth:
     - -
    2 digit month, 2 digit day, 4 digit year

  • NOT PAID IN FULL BY MY / OUR INSURANCE OR GOVERNMENT BENEFITS PROGRAM. SUCH PAYMENTS ARE DUE AT THE TIME OF SERVICE OR IMMEDIATELY UPON PRESENTATION OF THE BILL.
    • I / WE AGREE THAT WE SHALL REMAIN FINANCIALLY RESPONSIBLE FOR THE ABOVE NAMED PATIENT UNTIL I NOTIFY YOU IN WRITING AS TO THE CONTRARY. THIS GUARANTEE IS CONTINUING EVEN IF THE ACTUAL PATIENT, IF A MINOR, REACHES THE AGE OF MATURITY.
    • I / WE AUTHORIZE THE ABOVE LISTED MEDICAL PRACTICE AND ITS' AGENT(S) TO CONTACT MY INSURANCE PROVIDER AND THE EMPLOYER OF THE POLICY HOLDER TO VERIFY MY ELIGIBILITY FOR INSURANCE COVERAGE. I AUTHORIZE EXCHANGE OF MEDICAL, BILLING, AND COLLECTION INFORMATION WITH THE HEALTH CARE FINANCE ADMINISTRATION AND THEIR AGENT(S), MY / OUR INSURANCE COMPANY, AND ANY OTHER HOLDER OF INFORMATION NECESSARY TO OBTAIN PAYMENT FOR SERVICES RENDERED. IN ADDITION, I / WE AUTHORIZE YOU OR YOUR AGENT TO EXCHANGE PAST, PRESENT, AND FUTURE MEDICAL INFORMATION WITH THE PATIENT'S OTHER HEALTH CARE PROVIDERS IN ORDER TO ENHANCE AND PROMOTE THE CONTINUITY OF CARE FOR THE PATIENT.
    • I / WE HEREBY NAME AS ASSIGNEE AND ALSO INSTRUCT AND DIRECT ANY AND ALL OF MY / OUR INSURANCE COMPANY AND / OR GOVERNMENT BENEFITS PAYER TO PAY BY CHECK(S) MADE OUT AND MAILED TO THE ASSIGNEE :
    Thomas J. Chambers, D.P.M. 7525 East Broadway Road, Suite 10 Mesa, AZ 85208
    • IF MY POLICY PROHIBITS DIRECT PAYMENT TO PROVIDERS, I / WE HEREBY INSTRUCT AND DIRECT THE INSURANCE COMPANY TO ASSIGN THE CHECK TO ME AND MAIL TO THE ADDRESS HIGHLIGHTED ABOVE. FURTHERMORE, I / WE GRANT LIMITED POWER OF ATTORNEY TO SIGN MY / OUR NAME, DEPOSIT, AND NEGOTIATE ANY INSURANCE PAYMENT RECEIVED, AND APPLY IT TO MY / OUR OUTSTANDING BALANCE. I / WE AGREE TO PAY ANY REMAINING BALANCE AFTER INSURANCE REIMBURSEMENT IMMEDIATELY UPON NOTIFICATION. ANY INSURANCE PAYMENTS RECEIVED BY ME FOR ANY UNPAID BALANCE WILL BE IMMEDIATELY ENDORSED TO THE MEDICAL PRACTICE LISTED ABOVE. FAILURE TO DO SO MAY RESULT IN A SERVICE CHARGE OF 1.5% MONTHLY.
    • I / WE AGREE THAT A PHOTOCOPY OF THIS ASSIGNMENT SHALL BE CONSIDERED AS EFFECTIVE AS THE ORIGINAL AND THAT THIS ASSIGNMENT SHALL REMAIN IN EFFECT UNTIL CANCELED IN WRITING BY THE ASSIGNEE.
    • THIS INSTRUMENT CONTAINS THE ENTIRE AND ONLY AGREEMENT BETWEEN THE PARTIES AND THERE ARE NO OTHER PROMISES, REPRESENTATIONS, OR WARRANTIES, EITHER EXPRESSED OR IMPLIED. THE PROVISIONS OF THIS AGREEMENT SHALL NOT BE CHANGED OR MODIFIED EXCEPT FOR AN INSTRUMENT, IN WRITING, SIGNED BY THE PARTIES HERETO.

    • THERE WILL BE A CHARGE OF $30.00 FOR FILLING OUT DISABILITY, FMLA & SHORT-TERM DISABILITY FORMS - DUE AT THE TIME OF EACH SERVICE.
    • I UNDERSTAND THAT THERE WILL BE A $30 SERVICE CHARGE FOR ALL RETURNED CHECKS.
    • APPOINTMENTS NOT CANCELLED WITHIN 24 HOURS OF THE APPOINTMENT TIME WILL BE SUBJECT TO A $50 FEE THAT IS NOT PAYABLE BY MY INSURANCE COMPANY.

    THIS IS A DIRECT ASSIGNMENT OF MY / OUR RIGHTS AND BENEFITS UNDER THIS POLICY.
    I / WE HAVE READ COMPLETELY AND UNDERSTAND THE STIPULATIONS AND AGREEMENTS LISTED IN THE DOCUMENT ABOVE AND AGREE TO ABIDE BY ALL.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Chambers Foot and Ankle - 7525 East Broadway Road, Suite 10 - Mesa, AZ 85208
    Phone (480) 985-3730 - Fax (480) 985-4532

  • Date of Birth:
     - -
    2 digit month, 2 digit day, 4 digit year

  • Chambers Foot & AnkleNo-Show & Late Arrival Policy

  • We value your time and strive to provide timely care for all patients. To help us stay on schedule, we ask that you review and acknowledge the following policy.

  • No-Show/Late Cancellation Fee

  • If you miss your appointment or cancel with less than 24 hours notice, a $50 no-show fee will be charged to your account. This fee is not covered by insurance.

  • Late Arrival Policy

  • If you arrive more than 10 minutes late, we may need to reschedule your appointment in order to remain respectful of other patients' scheduled times. If rescheduling is necessary, it may be considered a no-show and subject to the $50 fee.

  • Why This Policy Matters

  • Missed and late appointments prevent other patients from receiving timely care and disrupt our schedule. This policy allows us to provide the best possible service to everyone.

  • Patient Acknowledgement

  • I understand and agree to the No-Show and Late Arrival Policy, including the $50 no-show fee and potential rescheduling for late arrivals.
  • Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Chambers Foot and Ankle - 7525 East Broadway Road, Suite 10 - Mesa, AZ 85208
    Phone (480) 985-3730 - Fax (480) 985-4532
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