Manhattan Podiatry Associates P.C.NYC Foot & Ankle OBS, P.C.

REGrsrfSJl?i FoRMToday's Date

Patient's Last Name

tr Mr. tr Miss

trMrs D Ms

Marital Status (Gircle One)

Single / Mar / Div / Sep / Wid

Birth Date Sex

t rM t rF

Address Social Security # Home Phone No.

City State ZIP Code E-Mail Address

Occupation Employer Business Phone No.

( )

Cell Phone No

Referred to Office by

D Advertiseme

O Doctor 0 lnsurance tr Internet

tr OtherOPatient/Friend

NAME OF PRIMARY INSURANCE

Policvholder's name. Policyholder's S.S. # Birth Date Group # Policy # Co-Payment

Patient 's Relat ionship to Policvholder tr Self O Spouse A Child O Other

NAME OF SECONDARY INSURANGE

Patient's Relationship to Policyholder O Spouse

Medical Doctor's Name/Address

lurrent foot complainUsymptoms

Name of Local Friend or Relative (not living at same address) Work Phone No( )

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I amfinancially responsible for any balance. I also authorize Manhattan Podiatry or insurance company to release any information required to process myclaims. I acknowledge that I was provided and read (or had the opportunity to read)and understood The Notice of Privacy Practiceam aware that the following information is available for viewing upon request;

o Information regarding the providers of care in this organization. A copy of the Patient's Bill of Rights and Responsibilities. Information regarding the grievance process. Ownership of Practice. DNR Policy. JCAHO lnformation

PATIENT/GUARDIAN SIGNATURE DATE