Gentle Foot Care Clinic

PATIENT INFORMATION FORM

INSURANCE INFORMATION
PLEASE UPLOAD PHOTOS (FRONT/BACK) OF YOUR INSURANCE CARD(S) AND ID (FRONT/BACK). *

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PRIMARY INSURANCE COMPANY NAME: *
ADDRESS:

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
INSURED NAME: *
DATE OF BIRTH *

Month Day Year
Date
EMPLOYER *
CONTRACT OR POLICY # *
GROUP #
SECONDARY INSURANCE COMPANY NAME: *
ADDRESS:

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
INSURED NAME:
DATE OF BIRTH

Month Day Year
Date
EMPLOYER
CONTRACT OR POLICY #
GROUP #

YOUR MEDICAL HISTORY
CLICK HERE IF YOU HAVE A PRINTED LIST OF YOUR MEDICATIONS ( PLEASE PROVIDE LIST TO THE MEDICAL ASSISTANT)

LIST PROVIDED
PLEASE LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING (INCLUDE PRESCRIPTIONS, OVER-THE-COUNTER MEDS AND HERBAL SUPPLEMENTS): *
What was your last Hemoglobin a1c?
ex: 6.5%
What is your height and weight? *
ex: 5'11" 120lbs
ALLERGIES: *

MEDICATIONS ANESTHESIA FOODS TAPE LATEX SHELLFISH IODINE NONE KNOWN
MEDICATION ALLERGIES
FOOD ALLERGIES
ANESTHESIA ALLERGIES

HAVE YOU EVER HAD ANY OF THE FOLLOWING? *

	Y	N
ACID REFLUX
ANEMIA
ARTHRITIS
ASTHMA
BACK TROUBLE
BLADDER INFECTIONS
ABNORMAL BLEEDING
BLOOD CLOTS
BLOOD TRANSFUSION
BRONCHITIS/EMPHYSEMA
CANCER
FIBROMYALGIA
GOUT
HEART ATTACK
HEART DISEASE/FAILURE
HEPATITIS
HIV+/AIDS
HIGH BLOOD PRESSURE
KIDNEY DISEASE
LIVER DISEASE
LOW BLOOD PRESSURE
MIGRAINE HEADACHES
MITRAL VALVE PROLAPSE
NEUROPATHY
OPEN SORES
PNEUMONIA
POLIO
RHEUMATIC FEVER
SICKLE CELL DISEASE
SKIN DISORDER
SLEEP APNEA
STOMACH ULCERS
STROKE
THYROID DISEASE
TUBERCULOSIS
VASCULAR DISEASE

DO YOU HAVE DIABETES? IF YES, WHICH TYPE: *

TYPE 1 TYPE 2 I DO NOT HAVE DIABETES

GENERAL CONSENT FOR CARE AND TREATMENT
HIPAA COMPLIANCE STATEMENT - THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

At Gentle Foot Care Clinic we are committed to protecting your privacy. We comply with all federal, state, and local laws. This notice describes how we use your health information. It describes some of your rights and some of our responsibilities.

UNDERSTANDING YOUR HEALTH RECORD/INFORMATION - Each time you visit our offices, we record your symptoms, physical examination, test results, diagnosis, and treatment. This information enables us to plan for your care, communicate with others who care for you, report to your insurance carrier, bill for our work, and improve the quality of our care.

YOUR RIGHTS - Although your medical chart belongs to our practice, the information contained in the chart is yours. You have the right to inspect your records, obtain a copy of your chart for a small fee, correct your records, and tell us not to release your information.

OUR RESPONSIBILITIES - We are required to maintain the privacy of your health information, send needed health information to other medical providers, and release information to insurance companies, certain government agencies, and others. We may be required to release some information, even without your permission.

EXAMPLES OF HOW YOUR INFORMATION IS USED - Your health information will be recorded and used to plan your treatment. Reports may be sent to other doctors to help them plan your treatment. Bills will be sent to your insurance company. The information in the bills will include confidential information such as your name, address, diagnosis, and treatment. In providing your care, we may communicate with other individuals or businesses. Examples include other physicians and/or laboratories. To protect your privacy, we ask our business associates to safeguard your information.

OTHER NOTICES - We may leave a message at your home, at your business, on your answering machine or on your voicemail. We may mail you a postcard or other written notices. We may need to disclose your information to your family members or other people helping with your care. In doing so, we will use our best judgment. We may disclose information to others as required by law or if subpoenaed. If you were injured on the job, we will need to disclose your health information to your workers compensation insurance company. We may, from time to time, update these policies.

FOR MORE INFORMATION OR TO REPORT A PROBLEM - If you have concerns or would like additional information, you may contact the practice’s Privacy Officer at 813-502-5904
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Date *

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Date

PATIENT FINANCIAL POLICY
Thank you for choosing Gentle Foot Care Clinic for your podiatric care. We are committed to providing you with quality and affordable health care. Because some of our patients have had questions regarding patient and insurance responsibility for services rendered, we have been advised to develop this payment policy. Please read it, ask us any questions you may have, and sign in the space provided. A copy will be provided to you upon request.

Insurance. We participate in most insurance plans, including Medicare. 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.

Co-payments and deductibles. 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. Please help us in upholding the law by paying your co-payment at each visit.

Non-covered services. Please be aware that some – and perhaps all – of the services you receive may be noncovered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of visit.

Proof of insurance. All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your driver’s license and current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim.

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 party to that contract.

Coverage changes. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim in 45 days, the balance will automatically be billed to you.

Nonpayment. If your account is over 90 days past due, you will receive a letter stating that you have 20 days to pay your account in full. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you and your immediate family members may be discharged from this practice. If this is to occur, you will be notified by regular and certified mail 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.

Missed appointments. Our policy is to charge for missed appointments not canceled within a reasonable amount of time. These charges will be your responsibility and billed directly to you. Please help us to serve you better by keeping your regularly scheduled appointment.

Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges for our area.

Thank you for understanding our payment policy. Please let us know if you have any questions or concerns.
Signature of Patient/Responsible Party: *

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Printed Name of Patient/Responsible Party
Date

Month Day Year
Date

CONFIRMATION
TO THE BEST OF MY KNOWLEDGE, I HAVE ANSWERED THE QUESTIONS ON THIS FORM ACCURATELY. 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.
PRINT NAME OF PATIENT, PARENT OR GUARDIAN
SIGNATURE OF DOCTOR

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IF OTHER THAN PATIENT, RELATIONSHIP TO PATIENT
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Date

Signature *

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PATIENT INFORMATION FORM