linwoodpodiatry.com - New Patient form

Charles T. Murphy, DPM
Podiatric Medicine and Surgery
Patient Registration
Patient Name *
Responsible Party Name *
Billing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Permanent Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Permanent Address is same as Billing Address *
Please upload ID *
Please upload Insurance copy *
Home Phone *

Area Code Phone Number
Cell Phone *

Area Code Phone Number
Work Phone *

Area Code Phone Number
Sex *

Male Female
Birth date *

Month Day Year
Age *
Patient SS# *
Marital Status *

S M W D
Responsible Party Name *
Birth date *

Month Day Year
Responsible Party SS# *
Relationship to patient *

Spouse Parent
Referring Physician or Referral Source
Phone

Area Code Phone Number
Date of Last Visit

Month Day Year

Is patient *

Yes

Employed

Full Time Student

Part time Student

Your Occupation *
Employer Name *
Address *
Phone *

Area Code Phone Number
Emergency Contact Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Relationship to patient *
Person Responsible for this bill *
Home phone *

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Responsible Party’s Employer
Work Phone

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Occupation
How did you hear of our practice? *
Friend/Relative
Physician

First Name Last Name
Phone Book

Area Code Phone Number
Web page
Other
INSURANCE INFORMATION

(PLEASE COMPLETE)
Primary Insurance Co. Name *

First Name Last Name
Insurance Co. Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Policyholder’s Name *

First Name Last Name
Birth date *

Month Day Year
Relationship to Patient *
Policy holder Sex *

Male Female
Employer *
Policy # *
Group # *
Co-pay $ *
Deductible *
Verified *
Secondary Insurance Co. Name *

First Name Last Name
Insurance Co. Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Policyholder’s Name *

First Name Last Name
Birth date *

Month Day Year
Relationship to Patient *
Policy holder Sex *

Male Female
Employer *
Policy # *
Group # *
Co-pay $ *
Deductible *
Verified *
AUTHORIZATION TO PAY

I hereby authorize payment directly to the business office of this physician for the surgical and/or medical benefits rendered to myself or to my dependents. I understand that I am responsible for any payment not covered by insurance.
Signature *

Clear
Date *

Month Day Year

FINANCIAL POLICY

Thank you for choosing Dr. Murphy and his staff for your podiatry needs. Our primary goal is to provide the best care possible. We have some basic guidelines concerning insurance and financial requirements. These guidelines help us to control health care costs by reducing our billing and collection costs. Should you have any questions regarding our financial policy, please contact our office.
- Insured patients-Co-pays are due at the time of service.
- Cash patients-payment is due at the time service is rendered.
- We accept Cash, Check, MasterCard, Visa and Debit for your convenience.
- There is a returned check fee of $25.00.
- Referrals: If you have an HMO or other managed care plan and are required to
  bring a referral, you must bring it with you on the date of your visit. If we do
  not receive the referral, you will be responsible for the charges. It is your
  responsibility to understand what your insurance company requires.
- If you are having financial troubles, please discuss them with our billing
  office. Please respect that we need to charge and get paid for the services we
  provide.
- Delinquent accounts will be turned over to the outside collection agency of
  our choice. Accounts are considered delinquent if unpaid after 90 days. In the
  event your account is turned over to collections, you will be required to pay
  this outstanding balance plus all applicable collection fees in full prior to
  resuming treatment with Dr. Murphy. Delinquent accounts are subject to
  dismissal.
All Billing Inquires should be directed to (609)653-2066 Monday –Friday 9:00am-4:30pm

I have read and understand the financial policy of the office of Dr. Charles T. Murphy, DPM.
Patient/Guardian Signature *

Clear
Date *

Month Day Year
Patient’s Name *

First Name Last Name
Date *

Month Day Year

Consent of Privacy Practices

I give this practice my consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies, and for health care opration such as quality review.

I have been informed that I may review the practice's Notice of Pravacy Practices for a more complete description of uses and disclosures before signing this consent.

I understand that this practice has the right to change their privacy practice and that I may obtain my revised notices at the practice.

I undrestand that I have the right to request a restriction of how my personal health information is used. However, I also understand that the practice is not required to agree to the request. If tne practice agree to my requested restricton, they must follow the restriction.

I also understand that I may revoke this consent at any time by making a request in writing except for information already use or disclosed.
Patient Name *

First Name Last Name
Date *

Month Day Year
Parent or Authorized Representative(if applicable)
Signature *

Clear
List any names and relationship of those individuals (ex.family members) that you wish to give consent for our office to disclose information regarding your care:
Should be Empty:

INSURANCE INFORMATION

Patient’s Medical Information