New Patient Forms | Ankle and Foot Specialists of Marion

Patient History

First name(Required)

Middle name(Required)

Last name(Required)

SS#(Required)

Name: Spouse, Parent or Guardian

By what name do you wish to be addressed?

Patient's Employer

Date of Birth(Required)

Age

Home Phone Number

Cell Phone Number(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Whom may we thank for referring you to our office?

Emergency Contact(Required)

Relationship(Required)

Phone(Required)

Marital Status(Required)

Single

Married

Widowed

Divorced

Primary Insurance(Required)

Insured Name(Required)

Insured DOB(Required)

Relationship(Required)

Secondary Insurance

Insured Name

Insured DOB

Relationship

Address of insured if different than the patient:

I have given permission for a message to be left with:

Family members: Yes

Family members: No

On answering machine: Yes

On answering machine: No

Family members(IF YES)

Podiatric History

Patient's name(Required)

Date(Required)

Name of Family Physician(Required)

City/State(Required)

Last visit(Required)

Family History: Siblings: Alive(Required)

Yes

Cause of death/age(IF NO)

Mother alive(Required)

Yes

Cause of death/age(IF NO)

Father alive(Required)

Yes

Cause of death/age(IF NO)

Past surgical history, date, surgeons, location of surgery, procedure and outcome:(Required)

Past Anesthesia history: Local/Date/problems?

Past Anesthesia history: General/Date/problems?

Current medications (strength & dosage)

Height(Required)

Weight(Required)

Shoe size(Required)

Diabetes: Do you test glucose every day?(Required)

Yes

Recreational Drug Use

Yes

Do you smoke? If so, how much and for how long?(Required)

Do you drink alcohol? If so, how much and how often?(Required)

Females: are you pregnant? Have you had a hysterectomy? If so, when?(Required)

Chief complaints(Required)

Nature of pain:(Required)

Sharp

Burning

Dull ache

Sore

Throbbing

Bruised

Pins & needles

Location of pain or lesion:(Required)

Onset:(Required)

Sudden

Gradual

Duration:(Required)

Frequency:(Required)

Constant

Intermittent

Timing:(Required)

Weight bearing

Non-weight bearing

Shoe aggravate

During work

Date of injury(Required)

Expectations of today's visit(Required)

NOTICE OF PRIVACY PRACTICE: THIS IS TO ACKNOWLEDGE THAT ANKLE & FOOT SPECIALISTS OF MARION, INC NOTICE OF PRIVACY PRACTICES HAS BEEN MADE AVAILABLE TO ME ON THE DATE STATED BELOW: IN ORDER FOR US TO SUBMIT A CLAIM FOR SERVICES COVERED UNDER YOUR POLICY, WE MUST HAVE YOUR AUTHORIZATION TO RELEASE MEDICAL INFORMATION TO YOUR INSURANCE CARRIER. I AUTHORIZE DR. TIMOTHY J. BROWN / DR. MATTHEW J. BROWN/DR. ANDREW J, BROWN TO FURNISH MY INSURANCE COMPANY WITH ALL NECESSARY INFORMATION REGARDING MY PRESENT ILLNESS OR INJURY. I ALSO AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO DR. TIMOTHY J. BROWN/ DR. MATTHEW J. BROWN/ DR. ANDREW BROWN FOR MEDICAL SUPPLIES OR SERVICES PROVIDED. I GIVE PERMISSION TO DR. BROWN TO EXAMINE AND TREAT MY ANKLE AND/OR FOOT CONDITIONS. IF SURGERY IS TO BE PERFORMED, THIS FORM IS TO BE USED IN CONJUNCTION WITH A SURGERY CONSENT FORM.

Signature of Patient/Parent/Guardian

PATIENT FINANCIAL POLICY

YOUR UNDERSTANDING OF OUR FINANCIAL POLICIES IS AN ESSENTIAL ELEMENT OF YOUR CARE AND TREATMENT. IF YOU HAVE QUESTIONS, PLEASE DISCUSS THEM WITH OUR FRONT OFFICE STAFF OR MANAGEMENT.

• AS OUR PATIENT, YOU ARE RESPONSIBLE FOR ALL AUTHORIZATIONS/REFERRALS NEEDED TO SEEK TREATMENT IN THIS OFFICE.

• UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE IN ADVANCE BY YOU, OR HEALTH INSURANCE CARRIER, PAYMENT FOR OFFICE SERVICES ARE DUE AT THE TIME OF SERVICE. WE WILL ACCEPT VISA, MASTERCARD, DISCOVER, CASH OR CHECK.

• YOUR INSURANCE POLICY IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE COMPANY. AS A COURTESY, WE WILL FILE YOUR INSURANCE CLAIM FOR YOU IF YOU ASSIGN THE BENEFITS TO THE DOCTOR. IN OTHER WORDS, YOU AGREE TO HAVE YOUR INSURANCE COMPANY PAY THE DOCTOR DIRECTLY. IF YOUR INSURANCE COMPANY DOES NOT PAY THE PRACTICE WITHIN A REASONABLE PERIOD, WE WILL HAVE TO LOOK TO YOU FOR PAYMENT.

• WE HAVE MADE PRIOR ARRANGEMENTS WITH CERTAIN INSURERS AND OTHER HEALTH PLANS TO ACCEPT AN ASSIGNMENT OF BENEFITS. WE WILL BILL THOSE PLANS WITH WHICH WE HAVE AN AGREEMENT AND WILL ONLY REQUIRE YOU TO PAY THE CO-PAY/CO-INSURANCE/DEDUCTIBLE.

• IF YOU HAVE NSURANCE COVERAGE WITH A PLAN WITH WHICH WE DO NOT HAVE A PRIOR AGREEMENT, WE WILL PREPARE AND SEND THE CLAIM FOR YOU ON AN UNASSIGNED BASIS. THIS MEANS YOUR INSURER WILL SEND THE PAYMENT DIRECTLY TO YOU. THEREFORE, ALL CHARGES FOR YOUR CARE AND TREATMENT ARE DUE AT THE TIME OF SERVICE.

• ALL HEALTH PLANS ARE NOT THE SAME AND DO NOT COVER THE SAME SERVICES. IN THE EVENT YOUR HEALTH PLAN DETERMINES A SERVICE TO BE “NOT COVERED”, OR YOU DO NOT HAVE AN AUTHORIZATION, YOU WILL BE RESPONSIBLE FOR THE COMPLETE CHARGE. WE WILL ATTEMPT TO VERIFY BENEFITS FOR SOME SPECIALIZED SERVICES OR REFERRALS; HOWEVER, YOU REMAIN RESPONSIBLE FOR CHARGES TO ANY SERVICES RENDERED. PATIENTS ARE ENCOURAGED TO CONTACT THEIR PLANS FOR CLARIFICATION OF BENEFITS PRIOR TO SERVICES RENDERED.

• YOU MUST INFORM THE OFFICE OF ALL INSURANCE CHARGES AND AUTHORIZATIONS/REFERRAL REQUIREMENTS. IN THE EVENT THE OFFICE IS NOT INFORMED, YOU WILL BE RESPONSIBLE FOR ANY CHARGES DENIED.

• FOR MOST SERVICES PROVIDED IN THE HOSPITAL, WE WILL BILL YOUR INSURANCE PLAN. ANY BALANCE DUE IS YOUR RESPONSIBILITY.

• THERE ARE CERTAIN ELECTIVE SURGICAL PROCEDURES FOR WHICH WE REQUIRE PRE-PAYMENT. YOU WILL BE INFORMED IN ADVANCE IF YOUR PROCEDURE IS ONE OF THOSE. IN THE EVENT, PAYMENT WILL BE DUE ONE WEEK PRIOR TO THE SURGERY.

• PAST DUE ACCOUNTS ARE SUBJECT TO COLLECTION PROCEEDINGS. ALL COSTS INCURRED INCLUDING , BUT NOT LIMITED TO, COLLECTION FEES, ATTORNEY FEES AND COURT COSTS SHALL BE YOUR RESPONSIBILITY IN ADDITION TO THE BALANCE DUE TO THIS OFFICE.

• THERE IS A SERVICE FEE OF $25.00 FOR ALL RETURNED CHECKS. YOUR INSURANCE COMPANY DOES NOT COVER THIS FEE.

• THERE IS A $25 FEE FOR ALL MISSED APPOINTMENTS WITHOUT GIVING PRIOR NOTICE OF CANCELLATION 24 HOURS IN ADVANCE.

SIGNATURE OF PATIENT/RESPONSIBLE PARTY(Required)

PRINTED NAME OF PATIENT/RESPONSIBLE PARTY(Required)

Date(Required)

PATIENT INITIALS TO INDICATE COPY RECEIVED(Required)