New Patient Registration Form

Please fill out this form to the best of your ability and sign for each appropriate section.

Patient Information

 

Name:         Social Security Number: 

Date of Birth:         Age:     Sex:     Relationship Status: 

Address:          

Home Phone:     Cell Phone:     Email Address: 

Pharmacy you would like prescriptions sent:   

Patient's Employer Information:     
 

Responsible party:   Relationship:     If Other, please explain: 

Responsible party's address: Same as Patient /       
 

In case of an emergency, name of person to contact:     
 

Is this work related?      If yes, date of injury:         Claim #: 
 

Primary Care Physician's information:   
 

How did you hear about our office? 
 

Authorized Disclosure

If patient is under the age of 18, a legal parent or guardian MUST accompany them for ALL visits. In the event that a parent or guardian is not able to attend the visit, a signed letter from the parent or guardian clearly stating the person authorized to consent to treatment must be brought for each visit.

Authorization to Disclose Health Information
**By selecting appointment information, this individual has the right to confirm, change, and cancel appointments, as well as know all past appointment history**

Name:     Relationship:  

May disclose (select all that apply): Billing Information        Medical Information        Appointment Information
 

Name:     Relationship:  

May disclose (select all that apply): Billing Information        Medical Information        Appointment Information
 

Insurance Information

Please have insurance cards in hand when arriving for the first appointment.

Insurance Company 1:    

        Primary Insured's:   Date of birth:     

        Policy Information:       Relationship To Insured:  
 

Insurance Company 2:    

        Primary Insured's:   Date of birth:     

        Policy Information:       Relationship To Insured:  
 

Patient OR Insured Signature (legal guardian signature if patient is a minor)
   

Reset Signature
Patient OR Insured Signature (legal guardian signature if patient is a minor)
 

Medical History

Reason for Visit: 
 

Shoe size:     Height:      Weight:     Do you smoke?   Packs/day:  
Past tobacco use?                                                                             Do you vape?   Per day use: 
                                                                                                                          Do you drink alcohol?  
Females: Are you pregnant?   Nursing? 

Have you had previous foot or ankle surgery? 
Have you ever worn custom made arch supports (orthotics)?
Do you have foot, calf, buttock, hip or thigh discomfort when you walk, which is relieved by rest? 
    (To include - aching, fatigue, tingling, cramping, or pain)
Do you experience any pain at rest in your lower leg(s) or feet?
Do you experience foot or toe pain that often disturbs your sleep?
Are your toes or feet pale, discolored, or bluish?
Do you have skin wounds or ulcers on your feet or toes that are slow to heal (8-12 weeks)?
Has your doctor ever told you that you have diminished or absent pedal (foot) pulses?
Have you suffered a severe injury to the leg(s) or feet?
Do you have an infection of the leg(s) or feet that may be gangrenous (black skin tissue)?
Have you experienced any falls over the last year?
 


Allergies - Please check those that apply:

 Penicillin  Iodine  Aspirin  Adhesive Tape  Sulfa
 Codeine  Seafood/Shellfish  Local Anesthetics  Latex Other 

Current Medications - Prescription and Non-prescription:


Prior Surgery:

Illnesses: (Please check all that apply)

 Anemia  Bleeding Disorders  Hepatitis  Lung Problems  Stroke Other 
 Arthritis  Diabetes  High Blood Pressure  Neck Pain  Cancer  
 Asthma  Gout  Kidney Problems  Numbness in Feet  HIV/Aids  
 Back Pain  Heart Disease  Liver Disease  Poor Circulation  Blood Clots  

Family History: (Please check all that apply)

 Anemia  Bleeding Disorders  Hepatitis  Lung Problems  Stroke Other 
 Arthritis  Diabetes  High Blood Pressure  Neck Pain  Cancer  
 Asthma  Gout  Kidney Problems  Numbness in Feet  HIV/Aids  
 Back Pain  Heart Disease  Liver Disease  Poor Circulation  Blood Clots  

I hereby give my permission to the doctor(s) at Laser Podiatry Associates to perform diagnostic, therapeutic and/or operative procedures as may be deemed necessary in diagnosis and/or treatment of my feet and/or ankles.

Patient OR Insured Signature (legal guardian signature if patient is a minor)

Reset Signature
 Patient OR Insured Signature (legal guardian signature if patient is a minor)
 

Financial Policy

 
Thank you for choosing our office to provide you with medical care. We are committed to serving you with skill and high-quality care. The medical services provided by our office are services you have elected to receive which may imply a financial responsibility on your part
INSURANCE: We participate in most insurance plans. If you are not insured by a plan we participate with, payment in full is expected at each visit. If you are insured by a plan we participate with but do not have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.
MEDICARE: We are a participating Medicare provider. We accept Medicare benefits amounts. Medicare as well as your secondary insurance (if any) will be billed for you. However; that does not mean that all services are covered. Patients are responsible for paying their annual deductible if it has not yet been met. You are also responsible for any copayments, which are usually 20% of the allowed amount for an item or service.
SECONDARY INSURANCE: Your medical claim will be forwarded to your secondary insurance (if any) after payment and/or explanation of benefits (EOB) is received from your primary insurance company.
SELF PAY: Payment in full is due at the time of service if you do not have health insurance.
NON-COVERED SERVICES: Please be aware that some of the services you receive may not be covered or not considered reasonable or necessary by Medicare or other insurers. You are responsible for full payment of these services at the time of service.
OPTIMUM CHOICE/MD IPA: X-rays done in our office are not covered. In an effort to eliminate sending you to a radiology facility where you would be responsible for a co-pay and/or deductible amount, we can perform your x-ray for a fee of $30.00 which is payable at the time of service.
REFERRALS/AUTHORIZATIONS: We are required to follow the guidelines of your managed care plan which mandates us that when you visit a specialist such as ours, you must have a referral from your primary care physician prior to seeking specialty care. Therefore, you are financially responsible for the services received, unless your referral is presented at the time of this visit. If you do not have a referral from your primary care physician at the time of a visit, you will be given the option to sign a release stating you will get the referral to our office within 72 hours. If the referral is not received within this time frame, you will be financially responsible for all services received. You will also be given the option to reschedule your appointment
CLAIM SUBMISSION: We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company.
PATIENT BILLING: All co-payments, co-insurance, or deductible amounts must be paid AT THE TIME OF SERVICE. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your portion of insurance benefits at each visit. As a courtesy, our office does verify benefits with your insurance carrier; however, the insurance agreement is a contract between you and your insurance carrier. It is recommended that you verify your benefits with your carrier as well. After the first billing cycle, interest in the amount of 1.5% per month (18% per year) will be added to any existing balances.
PHYSICIAN PHONE CALLS/PAPERWORK: Phone calls with our physician are a billable service, may be billed to your insurance company/companies, and are subject to your insurance benefits. You are responsible for your portion of insurance benefits for physician phone calls. Any forms, letters or any other necessary paperwork you need filled out will be charged to you at $20.00 per form after the first one. This fee MUST be paid prior to our office releasing the forms.
NON-CUSTOM DURABLE MEDICAL EQUIPMENT RETURNS: If a patient is unsatisfied with any noncustom Durable Medical Equipment item, it must be returned within 30 days per Medicare guidelines. Returns after 30 days will not be permitted. The item will only be accepted as a return if it is in returnable condition. Any custom durable medical equipment item may not be returned for any reason.
COPY FEE: We will provide copies of patient records at the patient’s request. Copies of records may be subject to a $0.25 per single page copy fee. You will bear complete financial responsibility for any fee(s) incurred. X-ray copies are $10.00 per film.
CANCELLED/MISSED APPOINTMENT FEE: If you cannot keep your appointment time, please call our office at least 24 hours prior to your scheduled appointment time. There may be a $45.00 fee for any appointment canceled without 24-hour notice. If you miss 3 or more appointments, you may be required to pay a $50 deposit to hold any future appointment time slots. If you arrive more than 15 minutes late for an appointment, we will reschedule your appointment. You will bear complete financial responsibility for any fee(s) incurred. Repeated missed or late appointments may result in dismissal from our practice.
COLLECTIONS FEE: You will be sent up to three notices for your financial responsibility (co-insurance, deductible) after payment and/or explanation of benefits (EOB) is received from your insurance company/companies. After the third and last notice, your account will be forwarded to our collection agency. If your account is sent to a collections agency, a 25% fee will be added to your account. You bear complete financial responsibility for any fee(s) incurred. Payment arrangements can be made on a case-by-case basis. We accept the following payment methods: Cash, Check or VISA/Mastercard/Discover/American Express. An additional $35.00 will be added to your statement if the check is returned from your bank. We do not accept starter checks. In the event that your insurance company sends payment to you, the patient, it should be forwarded to our office to be applied to your balance. I have read the above policy regarding my financial responsibility to Laser Podiatry Associates, LLC. for the medical services provided. I agree to pay Laser Podiatry Associates, LLC. any balance unpaid by my insurance carrier for myself or the person named below.
PRIVACY STATEMENT: Any information disclosed in your records will remain confidential and will not be used for any other reason except in providing quality care and treatment as well as to submit your claim to your insurance company and contact you as needed.
PATIENT ACKNOWLEDGE OF NOTICE OF PRIVACY PRACTICES: By subscribing my name below, I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have (or had the opportunity to read if I so chose) and understand the Notice and agree to its terms.

Assignment of Benefits

I, the undersigned, certify that I (or my dependent) have coverage with my insurance as presented and assign directly to Laser Podiatry Associates, LLC. all insurance benefits, payable to me for services rendered. I understand that I am responsible for payment of deductibles, co-payments, co-insurance, non-covered services and other fees AT THE TIME OF SERVICE. I hereby authorize the doctor to release all information necessary to secure payment of benefits. I authorize Release of Medical Information to my insurance carrier, or requested physician to provide continuity of care. I authorize the use of this signature on all insurance submissions.


I understand that it is my responsibility to inform the doctor’s office if there is a change in my health insurance information and acknowledge I was provided with a copy of the Notice of Privacy Practices and understand and accept its terms:
Patient Pateint Signature
Patient Name: 


Date:              

Reset Signature
Financially Responsible Party Responsible Party Signature
Name:           


Date:             

Reset Signature
Relationship to patient: 
 
By submitting, you agree that all of the information provided is filled out to the best of your ability and you've read the terms and conditions within the Financial Policy.