PATIENT REGISTRATION FORM

Guarantor Information: Complete if different from Patient 

Is your treatment today due to: 

I certify that the above information is true and correct to the best-on knowledge. I give permission to the doctor to administer and perform such as procedures as may be deemed necessary in the diagnosis and or treatment of my feet

I hereby authorize the release of any medical information pertaining to my treatment or information necessary for processing insurance claims and payment of medical benefits to myself or the party who accepts assignments. This authorization will remain valid until revoked by me in writing.

l understand that I am legally responsible for all charges whether or not reimbursed by my insurance campany.

MEDICARE SIGNATURE ON FILE

I request that payment of authorized Medicare benefits and if applicable Medigap benefits, be made on my behalf to Bay Area Foot Care, Inc. for services furnished to me by the listed provider/supplier. To the extent permitted by law, I authorize any holder of medical or other information about me to release to the Centers for Medicare and Medicaid Services, my Medigap insurer, and their agents any information needed to determine these benefits or benefits payable for related services.

I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If "other health Insurance" is Indicated in item 9 of the HCFA-1500 form, or else where on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the provider of supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier.

I acknowledge that I was provided with a copy of the Notice of Privacy Practices and that I have read (or had the opportunity to read if I so choose) and understand the Notice. 

Please read this information carefully:

With the changing world of healthcare and technology, we are offering our patients an electronic method of communication. You have the right to request that Bay Area Foot Care communicate with you via email and or SMS messaging. You also have the right to know the associated risks with the use of non-encrypted electronic communication.

The transmission of patient information by email and/or texting has a number or risks that patients should consider prior to consenting. These include, but are not limited to the following risks:

• Email and texts can be circulated, forwarded, stored electronically and on paper, and broadcast to unintended recipients.
• Email and text senders can easily misaddress an email or text and send the information to an undesired recipient.
• Backup copies of emails and texts may exist even after the sender and/or the recipient has deleted his or her copy.
• Employers and on-line services have a right to inspect emails sent through their company systems.
• Emails and texts can be intercepted, altered, forwarded or used without authorization or detection.
• Email and texts can be used as evidence in court.
• Emails and texts may not be secure and therefore it is possible that the confidentiality of such communications may be breached by a third party.

Conditions for the use of email and text messages:

Our office cannot guarantee but will use all reasonable precautions to maintain security and confidentiality of email and text information sent and received. Our office is not liable for improper disclosure of confidential information that is not caused by intentional misconduct.

Patients/Legal Guardians must acknowledge and consent to the following conditions:

• Email and/or texting are not appropriate for urgent or emergency situations. Our office cannot guarantee that any particular email and/or text will be read and responded to within any particular period of time.
• Email and texts should be concise. The patient /legal guardian should call and/or schedule an appointment to discuss complex and/or sensitive situations. 
• We will use email to communicate with you only about non-sensitive and non-urgent issues such as:
  • Questions about prescriptions. use of medical equipment or devices
  • Routine follow up questions
  • Appointinent scheduling
  • Billing questions
• Your e-mail messages may be forwarded to another office staff member as necessary for appropriate handling.
• Patients /legal guardians should not use email or texts for communication of sensitive medical information.
• Our office is not liable for breaches of confidentiality caused by the patient or any third party.
• It is the Patients / legal guardian's responsibility to follow up and/or schedule an appointment if warranted.

IN A MEDICAL EMERGENCY, DO NOT USE E-MAIL or TEXT MESSAGING...CALL 911

Reminder: do not use e-mail for urgent problems. If you have an urgent problem, call our office if during business hours or go to an urgent care facility.

At Bay Area Foot Care our goal is to provide quality Podiatry care in a timely manner. We have implemented a no show and cancellation policy which enables us to better utilize available appointments for our patients in need of Podiatric care. The following policy is with regard to patients who fail to keep their scheduled office visit appointment.

We request your consideration of other patients and ask that you contact Bay Area Foot Care promptly if you are unable to attend an appointment. This time will be reallocated to someone who is in urgent need of treatment. Available appointments are in high demand and your early cancellation will give another person the possibility to have access to timely care. Any cancelled or rescheduled appointments with less than a 24s-hour notice will be considered a "Late Cancellation".

Bay Area Foot Care reserves the right to charge $25.00 of any patient who fails to cancel their scheduled appointment two consecutive visits in a row. In the event of an actual emergency, consideration will be given, and a one-time exception may be granted.

How to cancel/re-Schedule Your Appointment:

To cancel or reschedule appointments call VALLEJO FOOT & ANKLE CLINIC (707)-643-3687 any problems getting through, you can leave a message with your name, appointment date and cancellation reason or request for rescheduling.