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  5 Franklin Av, Suite 103
Belleville, NJ 07109		 2633 Main Street, Suite 202
Lawrenceville, NJ 08648		 315 Broad Street
Florence, NJ 08518

Online New Patient Form:

NewPatientDetails Form v05-15

PATIENT INFORMATION:

INSURANCE INFORMATION:

Primary Insurance Information: 

Secondary Insurance Information: 

Details of Insurance Card Holder, Parent info if the patient is a minor, or person responsible for the account:

Preferred Pharmacy Details: 

CURRENT CONDITION/COMPLAINT:

Vein Screening Questionnaire:

REVIEW OF SYSTEMS:

Select all that you experience currently:

Medical History:

Select to all that you have or ever had previously?  (Select NONE for each if none)

‎
Abnormal Bleeding
Acid Reflux
Anemia
Arthritis
Asthma
Back Pain
Bladder Infections
Blood Clots
Blood Transfusion
Bronchitis/Emphysema
NONE of the ABOVE:
‎
Cancer
Diabetes
Dialysis
Fibromyalgia
Gout
Heart Attack
Heart Disease
Hepatitis
High BP
HIV/AIDS
NONE of the ABOVE:
‎
Kidney Disease
Liver Disease
Low BP
Migraines
Neuropathy
Open Sores
Parkinson’s
Pneumonia
Sciatica
Sickle Cell
NONE of the ABOVE:
‎
Skin Disorder
Stomach Ulcer
Stroke
Thyroid Disease
Tingling
Tuberculosis
NONE of the ABOVE:

If you have or had Diabetes, please provide following additional details: 

Allergies:

‎
Medical Allergies
Seasonal Allergies
Iodine Allergies
Local Anesthesia Allergies
Food Allergies
Other Allergies
NONE of the ABOVE:

MEDICATION HISTORY:

Please list all medications you are currently taking (Including prescriptions, Over the Counter Meds and Herbal Supplements): 

SURGICAL HISTORY:

FAMILY’S MEDICAL HISTORY:

MotherFatherBrotherSisterOthers
Arthritis
Cancer
Diabetes
Heart Disease
Hypertension
Stroke
Thyroid
Other (Specify below)
None

 

SOCIAL HISTORY:

HIPAA Release Form

Release of Information

I authorize the release of information including the diagnosis, records, examinations rendered to me and claims information. 

This information may be released to:

This release of information will remain in effect until terminated by me in writing.

Messages: 

Please Call

Home Phone Number: 

Work Phone Number: 

Cell Phone Number: 

How would you like to submit this New Patient Details form to Complete Foot & Ankle Specialty? 

 

Review and agree to below points:  

                       To the best of my knowledge, I have answered the questions on this form accurately & completely. I understand that providing incorrect information can be dangerous to my health. I understand that it is my responsibility to inform the doctor and office staff of any changes in my medical status.
I Agree
Click to view Legal
Assignment of Benefits…
 I have read and agree to Legal Assignment Of Benefits And Designation Of Authorized Representative.
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Legal Assignment Of Benefits And Designation Of Authorized Representative

In considering the amount of medical expenses to be incurred, I, the undersigned, have insurance and/or employee health care benefits coverage with the above captioned, and hereby assign and convey directly to the above named healthcare provider(s), as my designated Authorized Representative(s), all medical benefits and/or insurance reimbursement, if any, otherwise payable to me for services rendered from such provider(s), regardless of such provider’s managed care network participation status. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize the above named provider(s) to release all medical information necessary to process my claims under HIPAA. I hereby authorize any plan administrator or fiduciary, insurer and my attorney to release to such provider(s) any and all plan documents, insurance policy and/or settlement information upon written request from such provider(s) in order to claim such medical benefits, reimbursement or any applicable remedies. I authorize the use of this signature on all my insurance and/or employee health benefits claim submissions.

I hereby convey to the above named provider(s), to the full extent permissible under the law and under any applicable employee group health plan(s), insurance policies or liability claim, any claim, chose in action, or other right I may have to such group health plans, health insurance issuers or tortfeasor insurer(s) under any applicable insurance policies, employee benefits plan(s) or public policies with respect to medical expenses incurred as a result of the medical services I received from the above named provider(s), and to the full extent permissible under the law to claim or lien such medical benefits, settlement, insurance reimbursement and any applicable remedies, including, but are not limited to, (1) obtaining information about the claim to the same extent as the assignor; (2) submitting evidence; (3) making statements about facts or law; (4) making any request, or giving, or receiving any notice about appeal proceedings; and (5) any administrative and judicial actions by such provider(s) to pursue such claim, chose in action or right against any liable party or employee group health plan(s), including, if necessary, bring suit by such provider(s) against any such liable party or employee group health plan in my name with derivative standing but at such provider(s) expenses. Unless revoked, this assignment is valid for all administrative and judicial reviews under PPACA, ERISA, Medicare and applicable federal or state laws. A photocopy of this assignment is to be considered as valid as the original.

I have read and fully understand this agreement.

 
I Agree
Click to view Financial Policy
 I have read and agree to Financial Policy detailing appointment cancellation policy, coverage & payments.
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FINANCIAL POLICY

Commercial/Indemnity Subscribers:

For Office Services:
Payment is expected as services are rendered unless prior financial arrangements have been made. A receipt will be provided for you which can also be used for submission to any secondary insurance or health care accounts you may have.

For Surgical Services:
Our office will submit surgical fees to your health insurance carrier.

HMO & PPO Patients:
It is impossible for the staff to know everything about your health insurance coverage; they are often tailored to suit the needs of the employer. If you require a referral, you are responsible for obtaining one prior to your visit. If you require a referral, and are seen by the physician without one, you will be responsible for any charges. Please read the information booklet provided to you by your health insurance carrier.

In order to submit charges for services rendered, you will need to provide a referral from your primary physician, if required, copies of your health insurance and identification cards. Copay, if you have one, is required for each visit.

Medicare & Medicare HMO Patients:
We are participating providers for Medicare, therefore, you are responsible only for deductibles and the 20% co-insurance. If your primary or secondary health insurance carrier is an HMO, you will need to provide referrals from your primary physician. We will need copies of your health insurance identification cards.

Cancellation Policy:
As a courtesy and in order to accommodate all our patients, we ask that you give 24 hour notice for cancellation or rescheduling of an appointment.

A $35 fee will be charged for failure to comply with this request for regularly scheduled appointments. A $50 fee will be charged for an orthotic cast that is missed.

Durable Medical Equipment:
Please be advised that insurance companies have been giving out misinformation regarding all durable medical equipment including the following: Orthotics, Braces, Splints, etc…

Please assume that unless you have a written document from your insurance company, you are financially responsible for the device.

Although our office may file insurance forms, you understand that it is your responsibility to ensure that you are covered for the services rendered. If your insurance company does not pay such bills, for any reason, you understand and agree that you are liable for the payment in full.

Any bill not paid within thirty (30) days after it is sent, shall be charged an administrative fee of $5 per month on the outstanding balance until paid or financial arrangements are made. In the event it becomes necessary for us to send the claim to collections, there will be an additional administrative charge of $50.

Your signature below indicates:
  1. You understand and accept our policy of assignment of insurance benefits.
  2. You realize that non covered services will be billed directly to you as well as deductibles, co-insurance amounts.
  3. You attest to the accuracy and completeness of the medical insurance coverage information given.
  4. You authorize this office to release medical information necessary to process your claims and appeals.
  5. You authorize payment of medical benefits to our office.
  6. There is a returned check fee of $35.00
  7. You understand that having insurance does not guarantee payment.

I have read and fully understand this agreement.

 
I Agree
I have read and agree to HIPAA information communication, release & notice of privacy practices.
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(609) 512-1126
(609) 512-1126

I have read and fully understand this agreement.

 
I Agree

 

I agree to all selected above by signing here: 

Sign Here

Please click ‘Submit’ button once you agree to all terms above. Note, it may take some time to process the form once you click ‘Submit’.  Thank you.