Patient Information Sheet 091409

PATIENT INFORMATION SHEET

PODIATRY ASSOCIATES, P.C.

Today’s Date: _____________________

Welcome to our office. PERSONAL INFORMATION

Full Legal Name (how patient’s name is listed with insurance) __________________________________________________ Physical & Mailing Address:_________________________________________________________Apt.# __________ City_____________________________ State____ Zip Code: ___________ Home Phone (_____) _______________ Cell Phone (____) __________________ Date of Birth ____________ Gender: M F Marital Status: S M D W Age _____ S.S #_______ ______ _______ Employer ___________________________________________________ Employer’s Address _____________________________________________ Work Phone (_____) _______________ City________________________________________ State_______________________Zip Code________________ SPOUSE / SIGNIFICANT OTHER , PARENT and / or RESPONSIBLE PARTY INFORMATION

Full Name ____________________________________________Home Phone (_____) ________________________ Physical and Mailing Address: ______________________________________________________Apt #___________ City_____________________________ State_______ Zip Code __________ Cell Phone (_____) ________________ Employer _______________________________ Work Phone (____) ______________ Other Phone: (____) _____________ Employer’s Address __________________________________City______________ State____ Zip Code__________ EMERGENCY CONTACT INFORMATION

Full Name (other than above name)______________________________________ Relationship________________ Physical/Mailing Address: _________________________________________________________Apt. #___________ City__________________________ State______ Zip Code___________ Home Phone (_____) _________________ Cell Phone: (____) _______________ Work Phone (____) _______________ Other Phone: (_____) _____________ Nearest Friend/Relative not living with you: ________________________________ Relationship: ______________ Physical/Mailing Address: ________________________________ City_______________ State____ Zip _________ Who referred you to our office: __________________________________ Friend/Relative/Doctor______________ Primary Care Physician? ____________________________________ Date of last visit to your doctor: ___________ What bothers you about your feet? _________________________________________________________________ ALWAYS BRING YOUR INSURANCE CARDS TO EACH VISIT, PRESENT TO FRONT DESK TO MAKE SURE THERE ARE NO CHANGES IN POLICY ID, GROUP OR MAILING ADDRESS AND COVERAGE.

Primary Insurance Company Name: ___________________________ Policy ID# ______________________ Group # ________________ Patient’s Name – (as on insurance card): ____________________________ Subscriber’s Name (as on card) _______________________________________ Date of Birth _____________ Subscriber’s S.S. # ______ _____ _______ Relationship to Patient: ________________________ Secondary Insurance Company Name: _______________________________ Policy ID# ___________________ Group # ________________ Patient’s Name – (as on insurance card): ____________________________ Subscriber’s Name (as on card) _______________________________________ Date of Birth _____________ Subscriber’s S.S. # ______ _____ _______ Relationship to Patient: _________________________ If this is a Group Insurance through your Employer, please give Employer Name: ______________________________

Our office Does Not Accept Medicaid. If you have Medicaid you are responsible for bill. If you eligible to be on Medicare Part B or you are on Medicare Part B, Always present your Medicare card with any other insurance you have, even though you may have Seniors First, Total Care, Medicare Complete, Secure Horizons, Viva, Humana, Advantra Freedom, Blue Advantage or any other insurance that takes the place of Medicare Part B. We must have a copy of Medicare card for our records. Turn page over, read, sign and date at bottom—

AGREEMENT CONCERNING MY FINANCIAL RESPONSIBILITY to PODIATRY ASSOCIATES, P.C.

By Signing this form, the patient/and or responsible party Agrees to the following: Please Read Carefully. Even though we do file an insurance claim, you will be responsible for this account in the event that your insurance company does not pay the charges. The patient/or responsible party understands we are not liable by any other oral or written contract (exa. Divorce Decree) except for the information the patient and/or responsible party provides in this information sheet. I, hereby authorize Consent for Treatment necessary or desirable for the care of the patient mentioned on this form. This includes, but is not restricted to, medicine, performance of operation/procedures, and conduct of laboratory or x-rays, dispensing of supplies, that may be used by the attending doctor. The services you receive including supplies that are possibly covered by your insurance carrier will be filed to your insurance company, if your insurance does not cover the supplies and services, the patient, and/or responsible party is fully responsible for payment of all non-covered services and supplies. I, hereby authorize my insurance company to remit payment of medical benefits direct to this office for services provided by our physicians. Verification of insurance does not guarantee payment of claim, if insurance does not pay or respond to bill, I understand I am responsible for bill and agree to pay all charges not paid by my insurance. I understand there are some services and items for the maintenance of good health that may not be covered by your insurance carrier, (example: items that go into the patient’s shoes or used on their feet or nails; services not considered medically necessary by your personal insurance company standards). Not all insurance companies cover: Supplies, Orthotics and Therapeutic (Diabetic) Shoes. All coverage of benefits are determined by your insurance carrier/group, it is always best to check with your insurance company on your coverage and exclusions on foot care or Podiatry services, your copay, and deductibles. Supplies are non-refundable. Special ordered items such as Orthotics and Diabetic Shoes cannot be returned and are non-refundable. If I change insurance carriers, (example – if I have Medicare Part B insurance and you sign up for Healthsprings of Alabama, Viva, Secure Horizons, Advantra Freedom, Wellcare, Humana, Blue Advantage, etc.), we must be informed of changes with a copy of insurance card. When patient become Medicare age and signs up for Medicare Part B, it is patient’s responsibility to show doctor’s office the Medicare card and for as the patient to make sure the Insurance Carriers (Primary or Secondary are updated with changes). I understand it is my responsibility to make sure our office has the correct insurance information and copy of correct insurance card. It is also my responsibility to call my Primary Care Physician’s Office if my insurance requires prior authorization for visits to Podiatry Associates, PC; Dr. James H. Bowman and/or Dr. Robert I. Russell, and make sure the authorization is sent to Podiatry Associates, P.C. If authorization is not received by Podiatry Associates by the date of my visit, I will be required to pay for visit or reschedule my appointment. I, hereby acknowledge full responsibility for the payment of all services, and agree to pay all amounts due in full at time of service, (copay, deductible, non-covered items or services), unless other arrangements are made. If my account becomes delinquent, I agree to pay all costs of collection fees, including attorney fees. The fee can be an additional 33% - 50% added to the past due amount, and the debt will be reflected on your credit rating. I, hereby authorize the release of all medical records on the patient listed above to the referring and/or primary care physician, as well as all records necessary for the processing of insurance claims when or if requested.

I have read all of the above and understand my responsibility as the patient and/or responsible party. I agree to all responsibility listed above and consent to treatment by signing below: __________________________________________________ Signature of Patient, Parent, Guardian, or Responsible Party (Including patient 14 years of age and older)

____________ Date

_________________________________ Witness Signature PISrevised091409