palm beach foot and ankle - patient registration · 2019-11-15 · palm beach foot and ankle...
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DOB:
Sex□ Male □ Female S M D W
Retired? □ Y □ N Spouse's Name
Spouse's Phone
□ Y □ N Email Address
□ Asian □ White/Caucasian
□ Black/African American □ Other
□ Hispanic/Latino
Preferred Language □ Native American/Alaska Native
□ Native Hawaiian/Other Pacific Islander
PRIMARY PHYSICIAN
PHARMACY NAME
PRIMARY INSURANCE:
SECONDARY INSURANCE:
SIGNATURE DATE
RELATIONSHIP (if other than patient) REASON (if unable to sign)
I hereby authorize the release of any medical information pertaining to my treatment or information necessary for processing insurance claims and
payment of the medical benefits to myself or the party who accepts assignments. This authorization will remain valid until revoked by me in writing. I
understand that I am legally responsible for all charges whether or not reimbursed by my insurance company. I understand and accept that if I fail to pay
my bill or any monies due and owing Palm Beach Foot and Ankle by the scheduled due date, and fail to make acceptable payment arrangements to bring
my account current, PBFA may refer my delinquent account to a collection agency. I further understand that if PBFA refers my account balance to a third
party for collection, a collection fee will be assessed and will be due in full at the time of the referral to the third party. The collection fee will be
calculated at the maximum amount permitted by applicable law but not to exceed 30% of the amount outstanding. For purposes of this provision, the
third party may be a debt collection company or an attorney. If a lawsuit is filed to recover an outstanding balance, I shall be also responsible for any
costs associated with the lawsuit such as court costs or other applicable costs. Finally, I understand that my delinquent account may be reported to one
or more of the national credit bureaus.
SIG
NA
TUR
E
Group Number Date of Birth
Policy Holder (if other than patient)
Policy Number Relationship to Patient
Group Number Date of Birth
Fax Number
Address
Phone Number
Fax Number
INSU
RA
NC
E IN
FOR
MA
TIO
N
Palm Beach Foot and Ankle participates with Medicare and many other insurance networks. It is ultimately the patient's responsibility to ensure network
participation with the insurance company. PBFA cannot assume responsibility for network participation. Please provide a photo ID and insurance cards
to receptionist.
Policy Holder (if other than patient)
Policy Number Relationship to Patient
Do you have a living will?
Emergency Contact (other than spouse)/Relationship:
Phone #
PC
P/P
HA
RM
AC
Y Address
Phone Number
Date Last Seen
City/State/Zip Code Marital Status
Employer
Occupation
Palm Beach Foot and Ankle - Patient RegistrationP
ERSO
NA
L IN
FO
PATIENT NAME Appt Date/Time
Local Mailing Address SSN:
City/State/Zip Code Home Phone #
Alternate Address Cell Phone #
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
□
□
□
□
Patient Signature Date
MEDICARE SIGNATURE ON FILE
Patient Name (please print) Medicare Number
Patient Signature Date
WHOM MAY WE THANK FOR SENDING YOU TO OUR OFFICE?□ □
□ □
□ □
□ □
WORKER'S COMPENSATION / ACCIDENT INFORMATIONIs your treatment today due to a work related injury? □ Yes □ No
What is the date of your injury?
Do you have written authorization from your employer and comp carrier to be treated? □ Yes □ No
Is your treatment today a result of a motor vehicle accident? □ Yes □ No
What is the date of your injury?
Is your treatment today a result of an accident / liability case? □ Yes □ No
What is the date of your injury?
Patient Signature Date
Newspaper Insurance Provider List
Other Passed by Location
Other:
Authorization Expiration Date:
I request that payment of authorized Medicare benefits be made either to me or on my behalf of Palm Beach Foot and
Ankle for any services furnished me by the listed provider/supplier. I authorize any holder of medical information about
me to release to the Health Care Financing Administration and its agents any information needed to determine these
benefits or benefits payable to related services. I understand that my signature requests that payment be made and
authorizes release of medical information necessary to pay the claim. If "other health insurance" is indicated in item 9 of
the HCFA-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature
authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the
provider/supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is
responsible only for the deductible, coinsurance, and non-covered services. Coinsurance and the deductible are based
upon the charge determination of the Medicare carrier.
Provider: Palm Beach Foot and Ankle
Doctor Verizon Yellow Pages
Patient The Yellow Book
Palm Beach Foot and Ankle
I acknowledge that I was provided a copy of the Notice of Privacy Practices (posted in the reception room) and that I
have read them or declined the opportunity to read them. I understand the Notice of Privacy Practices discloses how we
may use and disclose my medical information.
I understand that this authorization is voluntary and if disclosed, it will expire one year from the date of execution if no
authorization date is given below. I acknowledge and agree that the practice may disclose my protected health
information and information contained in my medical record to the following:
Spouse:
Legal Representative:
Describe the pain/discomfort: □ Burning □ Numbness □ Sharp □ Other
When did the pain/discomfort begin?
What makes the pain/discomfort better?
What makes the pain/discomfort worse?
ALLERGIES: List all drug, food and environmental allergies and describe reaction: □ NONE
□ Penicillin □ Aspirin □ Narcotic Agent/Codeine□ Anesthesia □ Shellfish □ Sulfa Drugs□ Nickel/Metal □ Radiographic Contrast Dye
□ Other
MEDICATION HOW OFTEN MEDICATION HOW OFTEN
PROCEDURE DATE PROCEDURE DATE
FAMILY HISTORY (please check & list relationship)CONDITION SELF FAMILY/Relationship CONDITION SELF FAMILY/RelationshipANEMIA □ □ KIDNEY DISEASE □ □ARTHRITIS □ □ LIVER DISEASE □ □ASTHMA □ □ MENTAL ILLNESS □ □BLEEDING DISORDERS □ □ MITRAL VALVE PROLAPSE □ □CANCER □ □ MULTIPLE SCLEROSIS □ □CIRCULATION PROBLEMS □ □ NAIL DISORDERS □ □DIABETIC (how long?) □ □ NERVE DISORDERS □ □DIABETES AVG GLUCOSE □ □ OBESITY □ □EPILEPSY □ □ PHLEBITIS □ □FOOT PROBLEM(S) □ □ PULMONARY DISEASE □ □GOUT □ □ PNEUMATIC FEVER □ □HEART DISEASE □ □ STD □ □HEPATITIS □ □ SKIN PROBLEMS □ □HIGH BLOOD PRESSURE □ □ STOMACH/INTEST PROBLEMS □ □HIGH CHOLESTEROL □ □ STROKE □ □HIV/AIDS □ □ THYROID DISEASE □ □INJURY/TRAMA MAJOR □ □ VARICOSE VEINS □ □
DO YOU?Drink alcohol? Y N How often?
Smoke tobacco? Y N How often?
Have a history of drug abuse? Y N Explain
Caffeine Use? Y N Explain
DO YOU?Exercise? Y N Height:
Are you pregnant? Y N Weight:
Shoe Size:
Patient Signature Date
SOC
IAL
SOCIAL HISTORY
MIS
C
MISCELLANEOUS
MED
ICA
L H
ISTO
RY
MEDICATION: Please list all medications, herbal supplements, and vitamins.
If Medication list is attached, please check here. □
□ NONE
SURGERY: Please list all major surgery and date performed. □ NONE
FAM
ILY
History & Medical HistoryIt's important that we learn your history!
TOD
AY
'S V
ISIT
EXPLAIN YOUR FOOT/ANKLE PROBLEM □ RIGHT □ LEFT
□ Fever □ Chills □ Sweats □ Weight Change
HEAD / EYES / EARS / NOSE / THROAT
□ Wear Contact Lens □ Nosebleeds □ Neck Pain □ Dizziness
□ Double Vision □ Wear Eyeglasses □ Eyesight Problems □ Sore Throat
□ Difficult Swallowing □ Cataract □ Dentures □ Ringing in Ears
CARDIOVASCULAR
□ Chest Pain / Discomfort □ Cardiovascular Symptoms □ Heart Murmur
□ Swelling Lower Extremity □ Leg Pain with Exercise □ Palpitations
HEMATOLOGIC / LYMPHATIC
□ Bleeding Problem □ Swollen Glands □ Lymphoma
□ Anemia □ Skin Lump / Location
RESPIRATORY
□ Difficulty Breathing □ Wheezing □ Previous Pulmonary Disease
□ Exposure to TB □ Coughing □ Pulmonary Symptoms
GASTROINTESTINAL
□ Nausea □ Vomiting □ Diarrhea
□ Decrease in Appetite □ Abdominal Pain □ Constipation
ENDOCRINE
□ Often Thirsty □ Frequent Urination □ Thyroid Disease
□ Urinary Symptoms □ Prostate Problems □ Prior Kidney Disease
MUSCULOSKELETAL
□ Musculoskeletal Symptoms □ Feeling Weak □ Joint Pain, Arthralgia
□ Weakness of Limbs □ Prior Fracture
NERVOUS SYSTEM
□ Ataxia □ Speech Difficulties □ Headache □ Convulsions
□ Neuropathy □ Confusion / Disorientation □ Fainting
SKIN
□ Rash □ Ulcer □ Lesions □ Sun Sensitivity
□ Color Change □ Slow Healing □ Infections □ Cracking
□ Eczema (Pruritus) □ Growth □ Hair Loss
□ Dermatitis □ Rheumatoid Arthritis □ Lupus □ Collagen Vascular
□ Nervousness □ Tension □ Depression
Patient Signature Date
CONSTITUTIONAL
ALLERGIC / IMMUNOLOGIC HISTORY
PSYCHIATRIC
REVIEW OF SYSTEMS: Please check any of the following that you are currently experiencing or have recently experienced.
WELCOME INFORMATION
We would like to take this opportunity to welcome you to our office. We hope that your visit will be pleasant. If our staff can do anything
to make you feel more comfortable, please don’t hesitate to ask. Please read the following information regarding our office policies and
your financial responsibility. Please understand that your insurance is a contract between YOU and your INSURANCE COMPANY. We
are not a party to that contract. You will be responsible for any deductible and/or copayment at the time of service. Payment for all
services is due at the time that services are rendered unless payment arrangements have been approved in advance by our staff. We
accept cash, checks, MasterCard, Visa, and American Express.
We may accept assignments of insurance benefits in certain circumstances. You will be responsible for balances NOT covered or paid
by your insurance company. If payment is not received within 90 days from the date of service, you will be responsible for the balance
on your account. You will receive separate bills from outside laboratories or Pathologists if any lab work is performed as we do NOT
handle the billing for lab work done outside our office. We will gladly discuss your proposed treatment and answer any questions relating
to your insurance.
CONSENT FOR EVALUATION & TREATMENT
To the Patient: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical, or diagnostic
procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing
the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply
an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or any identified
condition(s).
This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and/or treatment. By
signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been
made and treatment recommended; and (2) you consent to treatment at this office or any other satellite office under common ownership.
The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services. You have the
right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you
have any concerns regarding any test/treatment recommended by your health care provider, we encourage you to ask questions.
I voluntarily request a physician, and/or other health care provider or the designees as deemed necessary, to perform reasonable and
necessary medical examination, testing, and treatment for the condition which has brought me to seek care at this practice. I understand
that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent
forms prior to the test(s) or procedure(s).
I have read and understand the financial policy of this office as it applies to me and will abide by it. I also certify that I have read and fully
understand the above statements and consent fully and voluntarily to its contents.
_________________________________________________________________ ___________________________________
SIGNATURE OF PATIENT OR PATIENT REPRESENTATIVE DATE
_________________________________________________________________ ___________________________________
SIGNATURE OF WITNESS DATE
Palm Beach Foot and Ankle
Dr. Alan Hartstein ● Dr. Hisham Ashry ● Dr. Jonathan Moskovits
Dr. Xavier Sanchez ● Dr. Jeffrey Rockefeller ● Dr. Kali Etheredge ● Dr. Kristin Silinski
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