Dr. Maurice W. Aiken Bay Breeze Foot & Ankle Specialists, P.L.L.C. 1022 Main St. Suite L, Dunedin, FL 34698 Phone(727) 734-5575 * Fax (727)733-4147 www.BayBreezeFeet.com

It is our practice to call or e-mail appointment reminders. It may also be necessary for our office to contact you for purposes of detailed medical and financial information. I authorize the practice to contact me by the following:

I hereby authorize Bay Breeze Foot & Ankle Specialists, PLLC, to release any information acquired in the course of my examination or treatment, that photocopies of this form will be as valid as the original,and that medical photographs may be taken in the course of treatment. Payment is expected when services are rendered, unless other arrangements are made in advance. I hereby authorize payment directly to Bay Breeze Foot & Ankle Specialists, PLLC, of the amount due me in my pending claim for medical expenses payable under the terms of my insurance. I agree that any balance not covered by my insurance will be paid by me.

Dr. Maurice W. Aiken Bay Breeze Foot & Ankle Specialists, P.L.L.C. 1022 Main St. Suite L, Dunedin, FL 34698 Phone(727) 734-5575 * Fax (727)733-4147 www.BayBreezeFeet.com

Social History

Dr. Maurice W. Aiken Bay Breeze Foot & Ankle Specialists, P.L.L.C. 1022 Main St. Suite L, Dunedin, FL 34698 Phone(727) 734-5575 * Fax (727)733-4147 www.BayBreezeFeet.com

I give my permission to allow my healthcare provider to obtain my mediaction history from my pharmacy, my health plans, and my other healthcare providers. 

Allergies - Please check known allergies and discribe the reaction.

Review of Systems

Bay Breeze Foot & Ankle Specialists

Dr. Maurice W. Aiken Bay Breeze Foot & Ankle Specialists, P.L.L.C. 1022 Main St. Suite L, Dunedin, FL 34698 Phone(727) 734-5575 * Fax (727)733-4147 www.BayBreezeFeet.com

 

Summary Of Notice Of Privacy Practice                                                  Karen T., Privacy Officer

This summary is provided to help you understand the Notice of Privacy Practices and describes how medical information about you may be used and disclosed and how you can get access to this information. Please review this notice carefully, the privacy of your medical information is important to us.

OUR LEGAL DUTY: We are required by applicable federal and state laws to maintain the privacy of your protected health information. We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your protected health information. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect April 14, 2003, and will remain in effect until we replace it. Copies of our complete notice of privacy practices, which contains a detailed description of how our office will protect your health care information, are located in the reception area and each treatment room. You may request a copy of our notice at any time.

USES AND DISCLOSURES OF HEALTH INFORMATION: We will use and disclose your health information in order to treat you or to assist other healthcare providers in treating you. We will also use and disclose your health information in order to obtain payment for our services or to allow insurance companies to process insurance claims for services rendered to you by us or other healthcare providers. Finally, we may disclose your health information for certain limited operational activities such as quality assessment, licensing, accreditation and training.

USES AND DISCLOSURES BASED ON YOUR AUTHORIZATION: Except as stated in more detail in the notice of privacy practices, we will not use or disclose your health information without your written authorization.

USES AND DISCLOSURES NOT REQUIRING YOUR AUTHORIZATION: In the following circumstances, we may disclosure protected health or financial information without your written authorization: To family members or close friends who are involved in your health. For certain limited research purposes. For purposes of public health and safety. To government agencies for purposes of their audits, investigations, and other oversight activities. To government authorities to prevent child abuse or domestic violence. To FDA to report product defects or incident. To law-enforcement authorities to protect public safety or to assist in apprehending criminal offenders. When required by court orders, search warrants, subpoenas, and as otherwise required by the law.

AS OUR PATIENT YOU HAVE THE FOLLOWING RIGHTS: To have access to and/or a copy of your health information. To receive an accounting of certain disclosures we have made of your health information. To request restrictions as to how your health information is used or disclosed. To request that we communicate with you in confidence. To request that we amend your health information. To receive notice of our privacy practices.

If you have a question, concern or complaint regarding our privacy practices, please refer to our detailed Notice of Privacy Practices or contact a staff member.

Podiatric Medicine * Sports Medicine  * Surgery of the Foot & Ankle  *  Alternative Foot Care

Dr. Maurice W. Aiken Bay Breeze Foot & Ankle Specialists, P.L.L.C. 1022 Main St. Suite L, Dunedin, FL 34698 Phone(727) 734-5575 * Fax (727)733-4147 www.BayBreezeFeet.com

All signatures below are the patient's unless the patient is unable to understand or sign. If a legally authorized representative is signing for the patient, please also print name and state relationship. By signing each section you are stating you fully understand and agree to that section of this document.

Acknowledgement of Notice of Privacy Practices

I acknowledge that I was provided a copy of the Notice of Privacy Practices for Bay Breeze Foot & Ankle Specialists prior to my signing this, and that I have read or had the opportunity to read if I so choose and understand the notice.

Financial Policy
An insurance policy is an agreement between you and your insurance company. Payment for services rendered and reimbursement from the insurer is ultimately the responsibility of the patient. If your insurance company requires a referral, it is your responsibility to obtain the necessary referrals for each visit. If we do not participate in your plan, payment is expected when services are rendered. Copays, deductibles, and charges for non-covered services are due at time of visit. Interest may be added to past due accounts in the amount of 1.5% monthly. If your account is sent out for collection, you will be responsible for and additional collection costs and attorney fees that may be incurred, including past due interest charges and a late payment service charge.

Medicare & Commercial Insurance Assignment of Benefits

I request that payment of authorized Medicare/Commercial benefits be made directly to me or on my behalf to Bay Breeze Foot & Ankle Specialists, PLLC, for any services or products furnished me by it's physicians. I authorize any holder of medical information about me to release to the Health Care Financing Administration and it's agents any information needed to determine these benefits, or the benefits payable for related services.

Dr. Maurice W. Aiken Bay Breeze Foot & Ankle Specialists, P.L.L.C. 1022 Main St. Suite L, Dunedin, FL 34698 Phone(727) 734-5575 * Fax (727)733-4147 www.BayBreezeFeet.com

Financial Policy

Your understanding of our financial policies is an essential element of your care and treatment.

If you have any questions, please discuss them with our front office staff or supervisor.

• As our patient, you are responsible for all authorizations/referrals needed to seek treatment in this office.
• Unless other arrangements have been made in advance by you, or your health insurance carrier, payment for office services are due at the time of service. We will accept VISA, MasterCard, Discover, cash or check.
• Your insurance policy is a contract between you and your insurance company. As a courtesy, we will file your insurance claim for you if you assign the benefits to the doctor. In other words, you agree to have your insurance company pay the doctor directly. If your insurance company does not pay the practice within a reasonable period, we will have to look to you for payment.
• We have made prior arrangement s with certain insurers and other health plans to accept an assignment of benefits. We will bill those plans with which we have an agreement and will only require you to pay the co-pay/co-insurance/deductible.
• If you have insurance coverage with a plan with which we do not have a prior agreement, we will prepare and send the claim for you on an unassigned basis. This means your insurer will send the payment directly to you. Therefore, all charges for your care and treatment are due at the time of service.
• All health plans are not the same and do not cover the same services. In the event your health plan determines a service to be "not covered," or you do not have an authorization, you will be responsible for the complete charge. We will attempt to verify benefits for some specialized services or referrals; however, you remain responsible for charges to any service rendered . Patients are encouraged to contact their plans for clarification of benefits prior to services rendered.
• You must inform the office of all insurance changes and authorization/referral requirements. In the event the office is not informed, you will be responsible for any charges denied.
• For most services provided in the hospital, we will bill your health plan. Any balance due is your responsibility.
• There are certain elective surgical procedures for which we require pre-payment. You will be informed in advance if your procedure is one of those. In that event, payment will be due one week prior to the surgery.
• Past due accounts are subject to collection proceedings. All costs incurred including, but not limited to, collection fees, attorney fees and court fees shall be your responsibility in addition to the balance due this office.
• There is a service fee of $30.00 for all returned checks. Your insurance company does not cover this fee.
• Patients will be charged a FEE for any missed appointment that does not receive a 24-hour cancellation notice.

Podiatric Medicine • Sports Medicine • Surgery of the Foot & Ankle • Alternative Foot Care