• New Patient Form

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  • Family History

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  • Notice of Privacy Act

  • Patient Contact

    We may contact you to provide appointment reminders, treatment information, billing and payment information, or for patient satisfaction surveys.

    Assignment and Release

    I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to Dr. Loren Miller all insurance benefits, if any, otherwise payable to me for services rendered, I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure payment of my benefits. I authorize the use of this signature on all insurance claim submissions.

       


    Allowed Uses and Disclosures of Your Medical Information:

    • Treatment – such as ordering diagnostic test
    • Payment – such as submitting information to your insurance company
    • Health Care Operations – such as quality assurance review, coordination of care, eligibility verification.


    In addition to the above, your medication information may be used or disclosed for emergency treatment; when we are required by law to treat you, we attempt to obtain consent, and if we are unable to obtain consent due to substantial communication barriers and consent for treatment is implied under the circumstances or we created or received the information in treatment.

    You have the right to:

    • Request a restriction on certain uses and disclosures; however we are not required to agree to any requested restrictions.
    • Receive confidential communication from us, upon written request.
    • Inspect and request copies of your medical information.
    • Request to amend copies of your incorrect or incomplete medical information.
    • Receive an accounting of any disclosures made, upon written request.
    • Receive a paper copy of the notice upon request.


    We are responsible for:

    • Maintaining the privacy of your medical information.
    • Providing you this notice.
    • Abiding by the terms of this notice.
    • Providing written notice of any change to this notice.

       


    Medicare and Insurance Authorization

    I request that payment of authorized Medicare or insurance benefits be made to me on my behalf to Dr. Loren Miller for any service furnished to me by that physician. I authorize any holder of medical information about me to be released to the Health Care Financing
    Administration and its agents; the information needed to determine these benefits or the benefits payable for any related services. I understand my signature request 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 elsewhere on other approved claim forms or electronically submitted claims, my signature authorized releasing of the information to the insurer or agency shown. In Medicare assigned cases, the physician, agency shown, or supplier agrees to accept the charge determination of the Medicare carrier as based upon the charge determination of the Medicare Carrier.

       


    Failure to Keep Scheduled Appointments
    If you are unable to keep your scheduled appointment, we ask that you please notify our office; at least 24 hours prior to your appointment time. Should you fail to provide proper notice, you will be charged $50.00 for the time that was allotted to you. By not contacting our office to cancel or reschedule your appointment, those in need of a time slot are unfortunately unable to see us. Thank you for your cooperation. I have read the above policies and I understand and agree to these policies.

       

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  • Medical History

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  • Podiatric History

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  • Foot Disorder

  • CONSENT

    I certify that the above information is correct to the best of my knowledge. I give permission to Dr. Miller to perform such procedures as may be deemed necessary in the diagnosis and/or treatment of my feet.

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  • Review of Systems

  • For new patients, established patients who may be having a new problem, or our patients who haven’t been seen for a while, we need to update our records as to your general medical health. In each area, if you are not having any difficulties, please circle “No.” If you are experiencing any of the symptoms listed, PLEASE CIRCLE YES. If you have any questions about this, please ask one of the technicians
    or the doctor.

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  • Our Financial Policy

  • Thank you for choosing us as your healthcare provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered part of your treatment. The following is a statement of our financial policy which we require you to sign prior to any treatment.

    All patients must complete our information packet and produce all insurance cards and id prior to seeing the doctor.

    CUSTOM MADE PRODUCTS (SHOES, INSERTS, ORTHOTICS, ETC.) ARE NON REFUNDABLE.

    24 Hours notice is required in the event you cannot keep your appointment. If notice is not given in a timely manner there is a mandatory $50.00 no show fee.

    ALL returned checks have a $25.00 processing fee applied to the account.

    Non insurance patients (self pay) full payment is due at time of service. We accept cash, check, credit card, etc.

    Regarding insurance

    We may accept assignment of insurance benefits. ALL co pays, coinsurance and deductibles are due at the time of service. In the event that your insurance is not in network you will be considered self pay. The balance is your responsibility whether your insurance company pays or not. Your insurance policy is a contract between you and your insurance company. We are not a third party to that contract. Please be aware that some, perhaps all, of the services provided may be non covered services and not considered reasonable under your insurance program.

    Usual and customary rates

    Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates.

    Adult patients

    Adult patients are responsible for their portion of payment at the time of service depending of self pay or insurance coverage.

    Minor patients

    The accompanying parent or guardian is responsible for full payment. For non accompanying minors, non emergency treatment will be denied.

    Thank you for understanding our financial policy. Please let us know if you have any questions or concerns. I have read the financial policy. I understand and agree to this financial policy:

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  • Consent for Biological Transfer

  • Florida law (Section 817 .5655, Florida Statutes) prohibits the sale or transfer of a person's biological specimen from which DNA can be extracted to a third party without the express consent of such person.

    During the course of your care at Advanced Foot and Ankle Surgery it may be medically necessary to obtain a blood, urine, stool, tissue or other type of biological specimen for analysis. This analysis will NOT involve the examination of your DNA to identify the presence and composition of genes in your body. After the analysis has been performed and the sample is no longer needed, it will be stored as medical waste and then transferred to a third party for disposal in accordance with all local, state and federal requirements.

    It may also be the case that a biological specimen (such as blood, urine, hair, bodily fluids, etc.) from you may be deposited on medical instruments, bedding, clothing or other objects. These objects may then be transferred to a third party for cleaning or disposal.

    By signing this document, you affirmatively state that it is your intentional decision to consent to the transfer of any and all biological specimens collected by or deposited with Advanced foot and Ankle Surgery to a third party as set forth above. This consent does not authorize the sale or transfer of a biological specimen for the purpose of DNA analysis.

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