new patient information · july 2015 1 5625 eiger road, suite 110 austin, tx 78735 (512) 447-4122...

July 2015 1

5625 Eiger Road, Suite 110

Austin, TX 78735 (512) 447-4122

southwestaustinfoot.com

Mark Whitesides, D.P.M. Board Certified, American Board of Podiatric Medicine Liza Chabokrow, D.P.M. Foot & Ankle Specialist

New Patient Information

First Name: ______________________________________ Last Name:_______________________________ MI: ____ Preferred Name: __________________________________ Sex: M F Date of Birth: ________________ Height: __________________________________________ Weight: _____________ Shoe size: ___________________ Address: _________________________________________________ City: _______________________ Zip: __________ Email Address for Access to Patient Portal: _____________________________________________________________ Cell Phone: ________________________ Home Phone: ______________________ Work Phone: ________________ Preferred phone (please circle): Cell Home Work May we leave a message? Yes No Ethnicity: Hispanic/Latino Race: American Indian or Alaska Native Primary Language: Not Hispanic/Latino Asian Decline to specifiy Black or African American _____________________ Native Hawaiian/ Other Pacific Islander Decline to Specify

White

Employer: ________________________________________ Occupation: ______________________________________

Primary Care Doctor: _____________________________________________ Phone Number: _____________________

Pharmacy Name and Location: ____________________________________ Phone Number: _____________________

Emergency Contact: ______________________________ Phone: _____________________ Relationship: _________

How were you referred to our office? __________________________________________________________________

☐ Physician Referral ______________________________ ☐ Web search ____________________________________

☐ Friend Referral _________________________________ ☐ Social Media ___________________________________

Insurance Information

Primary Insurance: _______________________________________________ Phone Number: _____________________

Policy Holder: _____________________________ DOB: _______________ Employer: __________________________

Policy ID Number: _______________________________________________ Policy Group Number: _______________

Secondary Insurance: ____________________________________________ Phone Number: _____________________

Policy Holder: _____________________________ DOB: _______________ Employer: __________________________

Policy ID Number: _______________________________________________ Policy Group Number: _______________

July 2015 2


Austin, TX 78735 (512) 447-4122



Medical History

Current Medications, including OTC and Herbal Supplements (Please attach medication list if necessary):

Drug: ____________________________________ Dose/Frequency: _____________ Date began taking: __________




Medication Allergies (name of drug and type of reaction):

Drug: ____________________________________ Type of Reaction: _________________________________________

Drug: ____________________________________ Type of Reaction: _________________________________________

Prior Surgeries:

Type of Surgery: ________________________________________________________ Date: _______________________



Recent hospitalizations (within the last 5 years):

Reason: ________________________________________________________________ Date: _______________________

Reason: ________________________________________________________________ Date: _______________________

Reason: ________________________________________________________________ Date: _______________________

Family Medical History (please check the appropriate boxes):

Mother Father Sibling Grandmother Grandfather

Diabetes

Cancer (Include Type)

Heart Disease

High Blood Pressure

Stroke

Thyroid Disease

Rheumatoid Arthritis

July 2015 3


Austin, TX 78735 (512) 447-4122



Please describe any medical problems that you are being treated for:

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

Please circle any conditions that you have ever experienced:

Anemia

Arthritis

Auto-Immune disease

Breathing disorders (shortness of breath, asthma, COPD)

Back pain

Blood clots

Cancer (include type:_________________________________________)

Diabetes (insulin-dependent or non-insulin dependent)

Dialysis (include schedule_____________________________________)

Gout

Heart Disease (Coronary Artery Disease, heart attack, Congestive Heart Failure, murmur, congenital heart defect)

Hepatitis

HIV/AIDS

Hypertension

Mental Illness (anxiety, bipolar disorder, depression, schizophrenia, other)

Migraine Headaches

Neuropathy

Pneumonia

Polio

Poor circulation

Seizure disorders

Skin disorders

Sleep apnea

Stomach ulcers

Stroke

Thyroid disease

Social History

Marital Status: Single Married Partnered Separated Divorced Widowed

Do you drink alcohol? Yes No How many drinks per week? ________________________________

Do you use tobacco? Yes No When did you begin?_________ When did you quit? __________

Never smoker Former smoker Heavy smoker Smoker Light smoker

Do you use recreational drugs? Yes No Type and Frequency: ______________________________________

Do you exercise? Yes No Type and frequency: ______________________________________

Hours per day on your feet: ___________________________________________________________________________

July 2015 4


5625 Eiger Road, Suite 110 Austin, TX 78735

(512) 447-4122 southwestaustinfoot.com

Current Foot or Ankle Problem(s)

Please describe your current problem(s):

____________________________________________________________________________________________________

____________________________________________________________________________________________________

Mark pain or discomfort on the diagram:

Please rate your pain from 1 (lowest) to 10 (highest): 1 2 3 4 5 6 7 8 9 10

Circle the type of pain you are experiencing: No pain Sharp pain Dull pain Aching Burning Itching Radiating Stabbing Other pain (please describe): _______________________________________ When did this problem start? _________________________________________________________________________

Did the problem develop suddenly or gradually? ________________________________________________________

What makes it feel worse (please circle)? Walking Standing Daily activities Resting Running Certain shoes Other:______________________________________________________________________________

What makes it feel better? ____________________________________________________________________________

How has this problem affected your lifestyle/ability to work? ______________________________________________

If this was caused by an injury, please describe: ______________________________________ Work related? Y N

Statement of Medical History Accuracy

“I have answered the questions on this form as accurately as possible. I understand that providing incorrect or misleading information can limit the physician’s ability to accurately diagnose and treat my condition. It is my

responsibility to inform the physician of any changes in my medical status.”

________________________________________________________________________ _____________________ Signature Date

________________________________________________ _____________________ _____________________ Responsible Person, if other than patient Relationship Date

July 2015 5




Financial Responsibility Policies

Fees for Service At the time of service, the patient is responsible for payment of any applicable co-pay, co-insurance or deductible. Southwest Austin Foot & Ankle Clinic accepts American Express, Visa, Master Card, Discover, and cash or check.

Insurance An insurance policy is a contract between the patient and the insurance company. It is the patient’s responsibility to inform the office of any changes in insurance, contact information, authorization or referral requirements.

Dr. Whitesides and Dr. Chabokrow perform many procedures that are coded as “surgical” by insurance companies in office, surgical center, and hospital settings. Fees for these services are typically subject to a different deductible than office visits.

We will make every effort to verify benefits with your insurance carrier prior to performing services. However, this is not a guarantee that all services provided will be covered. The patient is financially responsible for all charges.

Forms Policy Our office is happy to assist with the completion of administrative forms, including temporary disability forms, FMLA forms and work release forms. There is a $10 per page fee for this service.

Missed Appointments Missed appointments prevent other patients from receiving care in a timely manner. We require that patients provide at least 24 hours notice if they have to reschedule or cancel an appointment.

Past Due Accounts Patient accounts must be current in order to be seen by the physician. Past due accounts are subject to collection proceedings.

Returned Check Policy There is a service fee of $35.00 for all returned checks. This fee must be paid prior to subsequent visits and is not billable to your insurance company.

Privacy Policy

By signing this form, I acknowledge that I have been provided the opportunity to read and understand the Notice of Privacy Practices. Please sign below to indicate that you have read and agree to the policies on this form: ________________________________________________________________ ____________________ Signature of Patient or Authorized Representative Date ________________________________________________________________ ____________________ Printed Name of Patient Date of Birth

July 2015 6




Release of Protected Health Information

Complete Section A or B:

A) ☐ I authorize Southwest Austin Foot & Ankle Clinic to release my protected health information to the following person(s)/entity:

Name: ____________________________________ Phone: ____________________ Relationship: _________________ Name: ____________________________________ Phone: ____________________ Relationship: _________________ Name: ____________________________________ Phone: ____________________ Relationship: _________________

I authorize Southwest Austin Foot & Ankle Clinic to release information related to:

(please check all that apply)

☐ Diagnosis, Lab Work and/or Procedures ☐ Billing Information

Does the patient have a designated Medical Power of Attorney? ☐ Yes ☐ No

OR

B. ☐ I do not want my information shared with anyone except parties who would otherwise be entitled to this information, including, but not limited to, your insurance provider, primary care physician or other medical professionals involved in providing your care.

I understand that this authorization is voluntary. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and that the information may not be

protected by federal confidentiality rules. This consent will be considered valid until such time that I revoke it. I reserve the right to revoke it at any time. I understand that to revoke this

consent, I must provide written notice to Southwest Austin Foot & Ankle Clinic. _______________________________________________________ ____________________ Signature of Patient or Authorized Representative Date _______________________________________________________ ____________________ Printed Name of Patient Date of Birth

July 2015 7




Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. The privacy of your medical information is important to us.

We are required by applicable federal and state laws to maintain the privacy of your protected health information. We are also required to give you this notice about privacy practices, our legal duties, and your rights concerning your protected health information.

We must follow the privacy practices that are described in this notice and we reserve the right to change our privacy practices and the terms of this notice at any time, provided that such changes are permitted by applicable law. You may request a copy of our notice (or subsequent revised notice) at any time. For more information about our privacy practices, or for additional copies of this notice, please contact us using the information listed at the end of this notice.

Uses and Disclosures of Protected Health Information We will use and disclose your protected health information about you for treatment, payment, and health care operations. Following are examples of the types of uses and disclosures of your protected health information that may occur:

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. We will also disclose protected health information to other physicians who may be treating you. Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you. Health Care Operations: We may use or disclose, as needed, your protected health information in order to conduct certain business and operational activities. We will share your protected health information with third party “business associates” that perform various activities for the business. When an arrangement such as this takes place, we will have a written contract that contains terms that will protect the privacy of your protected health information. We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related services. Uses and Disclosures Based On Your Written Authorization: Other uses and disclosures of your protected health information will be made only with your authorization, unless otherwise permitted or required by law. You may give us written authorization to use your protected health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Other Uses and Disclosures of Your Protected Health Information: We may use and disclose your protected health information for purposes such as: Public Health and Safety, Research, Health Oversight, Abuse or Neglect, Food and Drug Administration, Criminal Activity, Court or Administrative Proceedings, providing to Others Involved in Your Health Care, or as Required by Law.

Patient Rights Access: You have the right to look at or get copies of your protected health information. You must make a request in writing to the contact person listed herein to obtain access to your protected health information. Accounting of Disclosures: You have the right to receive a list of instances in which we or our business associates disclosed your protected health information for purposes other than treatment, payment, health care operations and certain other activities. We will provide you with the date on which we made the disclosure, the name of the person or entity to whom we disclosed your protected health information, a description of the protected health information we disclosed, the reason for the disclosure, and certain other information. Restriction Requests: You have the right to request that we place additional restrictions on our use or disclosure of your protected health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Confidential Communication: You have the right to request that we communicate with you in confidence about your protected health information by alternative means or to an alternative location. You must make your request in writing and we must accommodate your request if it is reasonable. Amendment: You have the right to request that we amend your protected health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request if we did not create the information you want amended or for certain other reasons, and we would do so by providing you with a written explanation. If we accept your request to amend the information, we will make reasonable efforts to inform others, including people or entities that you name, of the amendment. Questions and Complaints If you want more information about our privacy practices or have questions or concerns, please contact us using the information below. IF you believe that we may have violated your privacy rights, or you disagree with a decision we made about access to your protected health information, you may complain to us using the contact information in the header of this form. You may also submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with that address to file your complaint upon request.

We support your right to protect the privacy of your protected health information.

Contact: Southwest Austin Foot & Ankle Clinic Privacy Coordinator, 5625 Eiger Road, Suite 110, Austin, TX 78735 Telephone: 512-447-4122 Email: [email protected]

new patient information · july 2015 1 5625 eiger road, suite 110 austin, tx 78735 (512) 447-4122...

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