Signature Foot & Ankle - New Patient Form

Insurance Information
Will you be using insurance for your visit?*

Yes, I'm using insuranceNo, I'll be paying out of pocket
Primary Insurance
Picture of Primary Insurance Card - Front

Cancelof
Picture of Primary Insurance Card - Back

Cancelof
Primary Insurance Company*
Insurance Phone #
Please enter a valid phone number.
Group #
Policy #*
Primary Subscriber - Employer Name
Relationship to Subscriber*
Primary Insured Subscriber
Primary Subscriber - Date of Birth

MonthDayYear
Date
Primary Subscriber - Phone #
Please enter a valid phone number.
Referral Needed*

YesNo
Secondary Insurance
Do you have secondary insurance*

YesNo
Picture of Secondary Insurance Card - Front

Cancelof
Picture of Secondary Insurance Card - Back

Cancelof
Secondary Insurance Company
Insurance Phone #
Please enter a valid phone number.
Group #
Policy #
Relationship to Subscriber
Primary Insured Subscriber
Primary Subscriber - Date of Birth

MonthDayYear
Date
Primary Subscriber - Phone #
Please enter a valid phone number.
Referral Needed

YesNo

Signature of Patient / Guardian
To the best of my knowledge, I have answered the questions on this form accurately. I understand that providing incorrect or incomplete 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. Parent or legal guardian name and signature required for individuals under age 18.
Printed Name of Patient, Parent or Guardian*

First NameLast Name
If other than Patient, relationship to Patient
Signature*

Clear

Photo and Promotional Release Form
I understand that photographs, videotapes, digital, or other images may be recorded to document my care, and I consent to this. I understand that Signature Foot and Ankle will retain ownership rights to these photographs, videotapes, digital, or other images, but that I will be allowed access to view them or obtain copies. I understand that these images will be stored in a secure manner that will protect my privacy and that they will be kept for the time period required by law or outlined in Signature Foot and Ankle’s policy. Images that identify me will be released and/or used outside the institution only upon written authorization from me or my legal representative.

I give my consent to have photographs, videotaped images, or other images made during the visit. I understand and agree that these images may be used by Signature Foot and Ankle for the purpose outlined below. They will not include any identifiable features when used outside of my chart. This includes, but is not limited to: Teaching purposes, which includes being shown to other patients, residency, and research. Advertisements for Signature Foot & Ankle.
Printed Name of Patient, Parent or Guardian

First NameLast Name
If other than Patient, relationship to Patient
Signature

Clear

Disclosure of Health Information

Consent to use and disclosure of health information for treatment, payment, or healthcare operations
Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that:
- Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
- The practice reserves the right to change the privacy policy as allowed by law.
- The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
- The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
- The practice may condition receipt of treatment upon execution of this consent.
May we discuss your medical condition with any member of your family?*

YesNo
Please name the members of your family we can discuss medical conditionals with:*
Printed Name of Patient, Parent or Guardian*

First NameLast Name
If other than Patient, relationship to Patient
Signature*

Clear
Should be Empty:

	Mother	Father	Sibling	Child
Blood Clots
Cancer / Tumor
Diabetes
Heart Disease
High Blood Pressure
Kidney Disease
Rheumatoid Arthritis
Stroke
Thyroid Disease
Other

General Information

Primary Care Physician

Pharmacy

Emergency Contact

Referral Source

Insurance Information

Primary Insurance

Secondary Insurance

Medications & Allergies

Family History

Past Medical History

Social History

Past Surgical History / Hospitalizations

History of Current Condition

Review of Symptoms

Patient Assessment

Signature of Patient / Guardian

Photo and Promotional Release Form

Disclosure of Health Information