PATIENT HEALTH INFORMATION

PATIENT HEALTH INFORMATION
Todays Date

MonthDayYear
Date
Patient Name*
Date of Birth*

MonthDayYear
Date
Shoe Size*
Activity Level*

MinimalModerateHigh
Sports*
Medication(s):

Medication List

	Name	Dose	Frequency
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5

Illness*

Heart DiseaseHigh Blood Pressure:DiabetesKidneyLungPVDArthritisCancerHeartburnHeadacheStrokeOther
Allergies*

Surgeries

	Date	Surgery Description
Surgery 1
Surgery 2
Surgery 3
Surgery 4

Any Family History of above Illnesses*
Social History*

SmokerDrink AlcoholOther
Today’s Complaint*
PATIENT DEMOGRAPHIC INFORMATION
Name*
DOB*
Age*
Social Security #*
Sex*

MaleFemale
Address*
City*
State*
Zip*
Do you give permission for Lone Star Podiatry to contact you by email?

YesNo
Email*
example@example.com
Home #*
Business #
Cell #*
Marital Status*
Employer*
Employer Phone #*
Language*
Race*
Ethnicity
Primary Care Physician Information:
Primary Care Physician:*
Primary Care Physician Phone #*
Pharmacy Name*
Pharmacy Address*
Emergency Contact*
Emergency Contact Phone #*
Relation to Patient*
Friend Referred by*

Primary DoctorWebsiteFriend :Other
Primary Insurance*
Insurance Phone #*
Address*
City*
State*
Zip*
Subscriber ID
Group #
Policy Holder
DOB
Relation to Patient
Secondary Insurance
Insurance Phone #
Subscriber ID
Group #
Policy Holder
Date

MonthDayYear
Date
Relation to Patient
Lone Star Podiatry Patient Payment Policy
Thank you for choosing our practice! We are committed to the success of your medical treatment and care. Please understand that payment of your bill is part of this treatment and care.

For your convenience, we have answered a variety of commonly-asked financial policy questions below. If you need further information about any of these policies, please ask to speak with a Billing Specialist or the Practice Manager.
How May I Pay?
We accept payment by cash, check, VISA, Mastercard, or Discover
What is My Financial Responsibility for Services?
Your financial responsibility depends on a variety of factors, explained below.
Office Visits and Surgeries

If you have…	You Are Responsible For:	Our Staff Will:
Commercial Insurance Also known as indemnity, “regular” insurance	Payment of the patient responsibility for all office visits, x-ray, injections, and other charges at the time of office visit.	Call your insurance company ahead of time to determine deductibles and coinsurance. File an insurance claim as a courtesy to you.
HMO & PPO plans with which we have a contract	If the services you receive are covered by the plan: All applicable copays and deductibles are requested at the time of the office visit. If the services you receive are not covered by the plan: Payment in full is requested at the time of the visit.	Call your insurance company ahead of time to determine copays, deductibles, and non-covered services for you & file an insurance claim on your behalf
HMO with which we are not contracted	Payment in full for office visits, x-ray, injections, and other charges at the time of office visit.	Provide the necessary information for you to complete and file your claim directly with the insurance company
Point of Service Plan or Out Of Network PPO	Payment of the patient responsibility – deductible, copay, noncovered services – at the time of the visit.	Call your insurance company ahead of time to determine out of network benefits, copays, deductibles, and noncovered services & file an insurance claim on your behalf
Medicare	Any services not covered by Medicare are requested at the time of the visit. If you have Regular Medicare as primary, and also have secondary insurance or Medigap: No payment is necessary at the time of visit	File the claim on your behalf, as well as any claims to your secondary insurance.
Office Appointment No Show	Letting us know 24 hours in advance if you can’t make an office appointment. Paying a $35 administrative fee if you aren’t able to cancel 24 hours in advance.	Confirm your appointment 1-2 days in advance of your appointment.
Procedure/Surgery Scheduling	We have a $100 deposit which is applicable to your deductible/coinsurance. It is non-refundable if you reschedule (more than once) or cancels less than 48 hours in advance.	Our staff will handle all your insurance authorization and questions. They will also coordinate with the surgery center
No insurance	Payment in full at the time of the visit.	Work with you to settle your account. Please ask to speak with our staff, if you need assistance.

• I have read, understand, and agree to the above Financial Policy. I understand that charges not covered by my insurance company, as well as applicable copayments and deductibles, are my responsibility.
• I authorize my insurance benefits be paid directly to Andrew Cassidy, DPM
• I authorize Andrew Cassidy, DPM to release pertinent medical information to my insurance company when requested, or to facilitate payment of a claim.
Date*

MonthDayYear
Date
Printed Name*
Signature*

Clear
Andrew Cassidy, DPM

Acknowledgment of Receipt of Privacy Notice

I have been provided with a Notice of Privacy Practices that provides me a more complete description of the uses and disclosures of certain health information. I understand Andrew Cassidy, DPM, reserves the right to change their Notice of Privacy Practices. I may request a copy of the updated Notice of Privacy Practices by calling my physician’s office or requesting a copy in person at my appointment.

The duration of this authorization is indefinite unless otherwise revoked in writing. I understand that requests for medical information from persons not listed below will require a specific authorization prior to disclosure of any medical information.
Patient’s Printed Name*
Date of Birth*

MonthDayYear
Date
Date*

MonthDayYear
Date
Patient Signature/ Legal Representative Signature*

Clear
Relationship to Patient*
Witness*
Date*

MonthDayYear
Date
The following names are of people I would like to be involved in or have access to my protected health information on a routine basis. I give permission for Andrew Cassidy, DPM, to share my protected health information with:
Name
Relationship
Name
Relationship
Name
Relationship

I wish to be contacted in the following manner:*

	Ok to leave a message with detailed information? Yes	Ok to leave a message with detailed information? No
Home Phone
Cell Phone
Work Phone

Should be Empty:

PATIENT HEALTH INFORMATION

PATIENT DEMOGRAPHIC INFORMATION

Primary Care Physician Information:

Lone Star Podiatry Patient Payment Policy

How May I Pay?

What is My Financial Responsibility for Services?

Office Visits and Surgeries