Aloha Foot Center New Patient Form

Aloha Foot Centers Registration Form
Have you or are you planning on filing a Worker's Compensation Claim OR a 3rd Party Liability Claim OR do you have Kaiser insurance (without added choice)?*

No, You may proceedYes, We do not take worker's compensation, 3rd party or Kaiser See below and Stop filling the form
STOP! WE DO NOT TAKE WORKER'S COMPENSATION, 3RD PARTY LIABILITY OR KAISER AND YOU WILL NEED TO PAY OUT OF POCKET FOR THE ENTIRE VISIT ON THE DAY OF YOUR APPOINTMENT.

CALL 808-266-0066 BEFORE GOING TO YOUR APPOINTMENT.
Patient First Name:*
Nick Name
Last Name*
Birthdate:*

MonthDayYear
Date
Age:*
If less than 18 years old, Name of parent
Gender:*
How did you hear about us?*
Family member/Friend/Internet
Primary Reason for Visit:*
Which Foot/Leg:*
Problem Area:*

Big ToeToenailsTop of footBottom of footHeelOutside ankleInside ankleLegOther
Take a photo of area of concern
Duration:*
When symptoms started?
How did this happen?*
Describe the circumstances around the injury or write NONE if unsure
Severity of Pain:*
Nature of Pain*

AchingBurningDullItchingNumbSharpShootingTenderThrobbingTinglingNo painOther
Course Of Problem*

ConstantWorseningImprovingIntermittentMorning PainNight PainEnd of day painOther
Previous Treatments*

Pain medsInsertsStretchingWent to ERNoneOther
Secondary Problems you would like to discuss?
Current Medications:*
If none, type 'none'
Preferred Pharmacy:*
Allergies*

NoneLatexiodineMetalOther
Past Medical History*

Anesthesia ProblemsAsthmaBack ProblemsBleeding DisorderBlood ClotCancerDementiaDepression/AnxietyDiabetic Type 2Diabetic Type 1DialysisDrugsFibromyalgiaGoutHepatitusHeart AttackHeart DiseaseHypertensionKidney DiseaseLeg Circulation ProblemLiver DiseaseLung DiseaseMRSA HistoryMultiple SclerosisNeurological DisorderNeuropathyPace MakerParkinsonRheum ArthritisSeizuresStomach UlcerStrokeThyroid DiseaseArtificial JointNoneOther
ROS: Have You Recently Had? Check all that apply*

FeverChills or Night SweatsWeight ChangeBlurred VisionPartial BlindnessDifficulty SwallowingHearing LossMouth or throat problemsNose or sinus problemsSkin RashSkin InfectionPainful Hand JointsBack or neck painCalf PainWeakness in arms or legsDizzinessNumbness, tingling or burningBalance problemsSwollen legsFrequent or painful urinationPregnant or BreastfeedingExcessive thirstTrouble with being too hot/coldCoughingShortness of BreathAbdominal PainNausea or VomitingDiarrheaChest pain or pressureBlood clotting problemDepressionNoneOther
List all past surgeries:*
If none, type none
Occupation:*
Occupation, Retired, Stay at home parent, Disability, Not working
Do you smoke?*
If Yes How many yrs?
If Yes How many packs/day?
Use recreational drugs?*
If Yes What type?
Do you drink alcohol?*
Primary Care Physician:*
Have you seen PCP in the last 6 months?*

YesNoUnsure
Family History (immediate family only parents/siblings):*

ArthritisBunionCancerDiabetesFlat FeetGoutHeart AttackStrokeUnsure of family historyAll of the above do not run in my immediate family historyOther
Family History: M=Mother F=Father B=Brother S=Sister
Arthritis

MFBS
Bunion

MFBS
Cancer

MFBS
Diabetes

MFBS
Flat Feet

MFBS
Gout

MFBS
Heart Attack

MFSB
Stroke

MFBS
Type of sport/exercise:
Hours per week?
Height:*
Weight:*
Shoe Size:*
Language:
Street Address:*
City, State:*
Zipcode:*
Billing Address:
if not the same as above (Street, City, State, Zipcode)
Who pays the medical bills?*

PatientOther
Mobile Phone #:*
Include area code if outside of Oahu or write NONE if you do not have any
Does the number have text capability?*
Landline Phone #:
Email Address:*
example@example.com or write NONE@None.com if you do not have any
Will you allow us to email office communications and bills?*
Durable Power of Attorney?
IF yes, what is their name:
Emergency Contact:
Emergency Contact #:
Will you allow us to discuss medical condition and billing with emergency contact?
Are you filling this form while in the office?

noyes
Primary Insurance Carrier Name:
Secondary Insurance Name (type none if no 2ndary):
Take Photo of Front of Insurance Card(s)
Take Photo of Back of Insurance Card(s)
Primary Insurance Carrier Name:*

AetnaAlohaCareBlue Cross Blue ShieldCignaDMBAGEHAHawaii LaborersKaiser Added Choice (we do not accept regular Kaiser)MedicareHMAHMAAHMSAHumanaOhanaPSWATricareUHAUHCVA (Need paper referral)Self PayOther
Primary Insurance Subscriber Number :*
Aetna - Which address is listed on back of the insurance card?*

El Paso, TX PO Box 981106El Paso, TX PO Box 981543Franklin, TN 800 Crescent CtrLexington, KY PO Box 14079Lexington, KY PO Box 14586Lexington, KY PO Box 14199Lubbock, Tx PO BOX 91604Pensacola, FL PO Box 3441Tampa, FL PO Box 30259Other
AlohaCare- Which AlohaCare do you have?*

Quest MedicaidMedicare Advantage Plus with subscriber number starting with MEMBoth Quest and MedicareUnsure
Cigna- Which address is listed on back of the insurance card?*

Austin, TX PO Box 30010Bourbonnais, IL PO Box 3298Chattanooga, TN PO Box 182223Chattanooga, TN PO Box 188004Chattanooga, TN PO Box 188007Chattanooga, TN PO Box 188008Chattanooga, TN PO Box 188013Chattanooga, TN PO Box 188030Chattanooga, TN PO Box 188050Chattanooga, TN PO Box 188061Kennett, MD 1000 great west driveSalt lake city, UT PO Box 30001Scranton, PA PO Box 5909St. Paul, MN PO Box 64143Wilmington, DE PO Box 15050Other
DMBA - Which address is listed on back of the insurance card?*

PO Box 45530PO Box 45730PO Box 44530Other
GEHA - Which address is listed on back of the insurance card?*

El Paso, TX PO Box 981707Salt Lake, UT PO Box 30783UnsureOther
HMA- Which HMA do you have?*

HMA AFLHMA Teamster HMOHMA UFCW- Hawaii PPOHMA Hawaii community health allianceunsureOther
HMSA- Which HMSA do you have, check back of insurance card as well to match address?*

Akamai Advantage medicareFederal, EUTF (Insurance comes from state or federal worker)HMO pacific health or Hawaii Health Partners (Requires paper referral)HMO all others no paper referral neededPPOPPO StevadoreQuest MedicaidunsureOther
Humana- Which Humana do you have?*

HMO gold plus, 500 Ala Moana Blvd Honolulu, HIPPO prime choice, 500 Ala Moana Blvd Honolulu, HIHumana PO Box 14601 Lexington, KYunsureOther
Ohana- Which Ohana do you have?*

Quest Medicaid (# leads with 0000)MedicareBothUnsureOther
Tricare- Which Tricare do you have?*

Tricare for life, MedicareTricare Select/ StandardTricare Prime (Paper referral required)Tricare Humana East Region (We do not accept this insurance)UnsureOther
Tricare & VA Insurances Enter Sponsor SS#*
UHC*

UHC AARPUHC MedicareUHC MDXUHC Quest medicaidunsureOther
UHC- Which PO Box or street address is listed on back of the insurance card?*
PO Box/ street & city & state
Do you have a secondary insurance?*

NoYesUnsure
Secondary Insurance Carrier Name:*

AetnaAloha careBlue Cross Blue ShieldCignaDMBAGEHAHawaii LaborersKaiser added choice ( We do not accept regular Kaiser)MedicareHMAHMAAHMSAHumanaOhanaPSWATricareUHAUHCVAOther
Secondary Insurance Subscriber Number:*
Aetna 2ndary- Which address is listed on back of the insurance card?*

El Paso, TX PO Box 981106El Paso, TX PO Box 981543Franklin, TN 800 Crescent CtrLexington, KY PO Box 14079Lexington, KY PO Box 14586Lexington, KY PO Box 14199Lubbock, Tx PO BOX 91604Pensacola, FL PO Box 3441Tampa, FL PO Box 30259Other
AlohaCare 2ndary- Which AlohaCare do you have?*

Quest MedicaidMedicare Advantage Plus with subscriber number starting with MEMBoth Quest and MedicareUnsure
Cigna 2ndary- Which address is listed on back of the insurance card?*

Austin, TX PO Box 30010Bourbonnais, IL PO Box 3298Chattanooga, TN PO Box 182223Chattanooga, TN PO Box 188004Chattanooga, TN PO Box 188007Chattanooga, TN PO Box 188008Chattanooga, TN PO Box 188013Chattanooga, TN PO Box 188030Chattanooga, TN PO Box 188050Chattanooga, TN PO Box 188061Kennett, MD 1000 great west driveSalt lake city, UT PO Box 30001Scranton, PA PO Box 5909St. Paul, MN PO Box 64143Wilmington, DE PO Box 15050Other
DMBA 2ndary - Which address is listed on back of the insurance card?*

PO Box 45530PO Box 45730PO Box 44530Other
HMA 2ndary- Which HMA do you have?*

HMA AFLHMA Teamster HMOHMA UFCW- Hawaii PPOHMA Hawaii community health allianceunsureOther
HMSA 2ndary- Which HMSA do you have, check back of insurance card as well to match address?*

Akamai Advantage medicareFederal, EUTF (Insurance comes from state or federal worker)HMO pacific health or Hawaii Health Partners (Requires paper referral)HMO all others no paper referral neededPPOPPO StevadoreQuest MedicaidunsureOther
GEHA 2ndary- Which address is listed on back of the insurance card?*

El Paso, TX PO Box 981707Salt Lake, UT PO Box 30783UnsureOther
Humana 2ndary- Which Humana do you have?*

HMO gold plus, 500 Ala Moana Blvd Honolulu, HIPPO prime choice, 500 Ala Moana Blvd Honolulu, HIHumana PO Box 14601 Lexington, KYunsureOther
Ohana 2ndary- Which Ohana do you have?*

Quest Medicaid (# leads with 0000)MedicareBothUnsureOther
Tricare 2ndary- Which Tricare do you have?*

Tricare for life, MedicareTricare Select/ StandardTricare Prime (Paper referral required)Tricare Humana East Region (We do not accept this insurance)UnsureOther
2ndary Tricare & VA Insurances Enter Sponsor SS#*
UHC 2ndary*

UHC AARPUHC MedicareUHC MDXUHC Quest medicaidunsureOther
UHC 2ndary- Which PO Box or street address is listed on back of the insurance card?*
PO Box/ street & city & state
1. Insurance.We participate in most insurance plans, including Medicare. We must obtain a copy of your driver’s license and current valid insurance to provide proof of insurance. If you are not insured by a plan we do business with, payment in full is expected at each visit. If you are insured by a plan we do business with, but don’t 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. 2. Co-payments and deductibles and deposits.All co-payments and deductibles 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. Deposits may be due at time of service depending on your insurance and treatment type. 3. Claims 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; we are not a party to that contract 4. Financial hardship. If you are having financial hardships and are unable to pay your co-payments and medical bills consider applying for Medicaid Quest assistance. If you qualify Quest plans have no copays. Return to clinic with your Quest insurance card and we will be able to continue seeing you as a patient and will negotiate and possibly reduce past due debt. 5. Nonpayment.If your account is over 90 days past due, you will receive a letter stating that you have 30 days to pay your account in full. Partial payments with recurrent credit card payments can be negotiated and set up. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you may be discharged from this practice. If this is to occur, you will be notified that you have 30 days to find alternative medical care. During that 30-day period, our physician will only be able to treat you on an emergency basis.

Practice Requirements – HIPAA COMPLIANCE -This Notice is in effect as of 4/15/03. Aloha Foot Centers: a) Is required by federal law to maintain the privacy of your Personal History Information (PHI) and provide you with this privacy notice detailing the practice’s legal duties and privacy practices with respect to your PHI. b) Under the Privacy Rule, may be required by State law to grant greater access or maintain greater restrictions on the use or release of your PHI than that which is provided for under federal law. c) Is required to abide by the terms of this privacy notice. d) Reserves the right to change the terms of this privacy notice and to make the new privacy notice provisions effective for all of your PHI that it maintains. e) Will distribute any revised privacy notice to you prior to implementation. f) Will not retaliate against you for filing a complaint. I acknowledge I have read this notice, understand the information and agree to its terms. I can have a copy of this notice at any time. I certify that the above information is complete and correct to the best of my knowledge. I give permission to Aloha Foot Centers to file all medical claims on my behalf. I request that payment of authorized benefits be made to Aloha Foot Centers on my behalf for medical services rendered to me. I consent to have my photo taken for my medical records.

I have read and understand the HIPAA and Payment Policy and agree to abide by its guidelines.
Signature of Patient or Signature of legal guardian responsible for bill*

Clear
Relationship to patient
Date*

MonthDayYear
Date
Signature of patient / Signature of legal guardian responsible for bill Relationship to patient Date Page 2 of 2
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