New Patient Form

Located In Troy, Ohio

contact@activefootohio.com

If You Prefer Printable Form Click Here To Download

Patient Information:

First Name*

Last Name*

Date of Birth*

City / State / Zip*

Address*

Primary Phone*

Secondary Phone

SS#*

Email*

Employer

Work Phone

Occupation

Marital Status*

Sex*

Age*

Shoe Size*

Weight*

Preferred Language*

Race*

Ethnicity*

Famliy Doctor*

Preferred Pharmacy*

Preferred Pharmacy City*

Who Referred You To Our Office*

Do You Smoke?*

If So, How Much?

Do You Drink Alcohol?*

Do You Use Drugs?*

(Women) Are You Currently Pregnant?

Primary Insurance Holder Information:

Insurance Carrier Name*

Member ID*

Name of Insured *

Relationship to Patient*

Address of Insured*

Date of Birth of Insured*

SS# of Insured*

Phone of Insured*

Secondary Insurance Holder Information:

Insurance Carrier Name*

Member ID*

Name of Insured*

Relationship to Patient*

Address of Insured*

Date of Birth of Insured*

SS# of Insured*

Phone of Insured*

Emergency Contact Information:

Name*

Relationship*

Phone*

Today's Problem?*

How Long?*

Location?*

Severity (How Severe if the pain)?*

Patient Health History:

In order for us to obtain a complete medical history, it is important for you to fill out this form as completely as possible. This is very important information. Please fill out every item. It is important for your doctor to know you have carefully reviewed every area of this form. This information will be entered into the computer and you are welcome to a copy of the report if you wish.

Please List Any Medications You Are Currently Taking:

Name of Medication

Dosage

How Often Taken

Name of Medication

Dosage

How Often Taken

Name of Medication

Dosage

How Often Taken

Name of Medication

Dosage

How Often Taken

Name of Medication

Dosage

How Often Taken

Are You Allergic To Any Medications?*

If Yes, Please List Below:

Non-Medication Allergies:

Are you allergic to any non-medical items such as:*

Surgeries & Hospitalizations:

Have you ever been hospitalized for non-surgical reasons?*

If Yes, Please List Reasons:

List any surgeries you have had including dates:

Patient Medical History:

Cancer*

Type:

Hepatitis*

Type:

Heart Attack*

Heart Disease*

Asthma*

Tuberculosis*

High BP*

Ulcer*

Kidney Disease*

Liver Abnormality*

Arthritis*

Stroke*

Anxiety*

Depression*

Diabetes*

Anemia*

Is there a family history of diabetes?*

If Yes, Who?

I give permission to Active Foot & Ankle to obtain medication history from my local pharmacy, Primary Care Physician, and any other Physician I may have received treatment from.

X-Rays & Photographs: I understand that in the course of my treatment I may have radiographs (X-Rays); I agree to inform the doctor or technologist if I am or may be pregnant. I authorize the physician and his assistant to take photographs. The term “photograph” includes digital, standard photographs, videotapes, etc. These photographs are property of Active Foot & Ankle and will be a permanent part of the record. These may be used for teaching, lectures, educational conferences, or publications.

*By submitting your name in this form verifies as your signature

Patient/Responsible Party Signature*

Date* dd/mm/yyyy

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL/PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Summary: By law, we are required to provide you with our Notice of Privacy Practices (NPP). This Notice describes how your medical information may be used and disclosed by us. It also tells you how you can obtain access to this information.

As a patient, you have the following rights:
1. The right to inspect and copy your information;
2. The right to request corrections to your information;
3. The right to request that your information be restricted;
4. The right to request confidential communications;
5. The right to a report of disclosures of your information; and
6. The right to a paper copy of this notice.

We want to assure you that your medical/protected health information is secure with us. This Notice contains information about how we will insure that your information remains private

Acknowledgement of Notice of Privacy Practices
“I hereby acknowledge that I have received a copy of this practice’s NOTICE OF PRIVACY PRACTICES. I understand that if I have questions or complaints regarding my privacy rights that I may contact the Privacy Officer. I understand that the practice will offer me updates to this NOTICE OF PRIVACY PRACTICES should it be amended or changed in any way.”

I expressly consent to receiving telephone calls from an automatic telephone dialing system, artificial and/or pre-recorded messages, emails, text messages, or other electronic communication from Active Foot and Ankle, and/or their contractors, servicers, debt collection agencies, or agents for any reason by using any telephone number, email address, and/or mailing address associated with my account or obtained by such entities. I agree that my consent may only be revoked by sending a written notice to Active Foot and Ankle or their agents. I agree to arbitrate any claims under the Telephone Consumer Protection Act, and I waive any right/ability to bring a class action against claims, against Active Foot and Ankle, and/or their contractors, servicers, debt collection agencies, or agents. (This is for internal office use only. We do not sell your information to outside companies.)

*I authorize my physician and her staff to communicate information regarding appointments, medical results, and billing issues to the following person(s). Please print name and indicate your relationship.

Name*

Relationship*

Name

Relationship

Cancellation Policy
Please give a 24-hour notice prior to canceling any scheduled appointment so that we may utilize available appointments for our patients in need of medical care. If you do not cancel your scheduled appointment you will be considered a “No Show” appointment and will be billed a $25.00 no show fee. After three “No Shows” you will be discharged from the practice. If you arrive 15 minutes past your scheduled appointment time the office has the right to reschedule your appointment.

*By submitting your name in this form verifies as your signature

Patient/Responsible Party Signature*

Date* dd/mm/yyyy

Patient Financial Agreement

• Self-pay patients - Payment in full is due at the time of service.

• Patients with Insurance - We will file your insurance claim for you. However, in order to work with your insurance company, we must have complete and current information as well as a copy of your insurance card and your signature on file.

• Denied Claims - You will be responsible for any charges that are denied by your insurance company which result from your failure to provide our office with complete and current information in a timely manner. It is your responsibility to inform us of any changes in insurance benefits.

• Referrals - If your insurance requires that you obtain a referral from your Primary Care Physician, it is your responsibility to ensure that our office receives the referral prior to your visit. If a referral is not in place, you will be responsible to pay in full at the time of service. If the doctor schedules a test for you, please check with your insurance to see if a prior-authorization is required (as this must be completed before testing is performed). Although we do our best to check for you, it is ultimately the responsibility of the patient.

• Durable Medical Equipment - Our office will assist in determining coverage for Durable Medical Equipment (braces, splints, boots, walkers, and/or orthotics as needed). Active Foot and Ankle makes every effort to verify active coverage, but we are not always able to check benefits on all patients, due to regulations of various insurance companies and contract agencies. All processes and procedures must be listed and billed according to HIPPA (Health Insurance Portability and Accountability Act) guidelines by Active Foot and Ankle for accuracy and liability purposes. This means any and all procedures, treatments and care will be billed to you and your insurance. This does not guarantee payment by your insurance company. Any item not covered by insurance is deemed “patient responsibility.”

• Insurance benefits – It is your responsibility to know your insurance benefits. Please contact your insurance company with any questions that you may have regarding coverage of podiatric services.

• Copayments, Co-Insurances and Deductibles – All patient balances are due at the time of service. Patients with private insurance plans (non-Medicare/Medicaid) that include deductibles will need to pay a $100.00 deposit at the time of service. If copays are required by your plan, payment at time of service will also be due. Active Foot and Ankle reserves the right to refuse treatment if required payments are not made at the time of service. For your convenience, all major credit cards are accepted.

• Non-Covered Charges - Please understand there may be some charges for our services which your insurance company considers non-covered and may be excluded from your policy. Accordingly, you will be responsible for these charges.

• Medicare - We are a participating Medicare provider. We will bill Medicare, as well as any secondary insurance that you may have. As per any insurance carrier, this does not mean that all services will be covered. Additionally, if you do not have a secondary insurance, you will be responsible for any copayments (20% of the Medicare allowed amount), as well as any unmet annual deductibles. Please realize that Medicare may allow a service, but your secondary may not, so you will be responsible for that portion.

• Returned checks – Any returned check is subject up to a $45.00 bank fee.

• Past due accounts – We will send a statement to the mailing address you provide notifying you of any outstanding balances. If you do not respond to the first statement within 30 days of receipt and additional statements are mailed, a $10 re-billing fee will be added each month. If you are not able to pay your balance in full, you must contact out billing office to discuss a possible payment plan. If you then fail to make payments, your account may be referred to a professional collection agency and/or attorney and will be subject to a 35% fee.

I HAVE READ, UNDERSTAND AND AGREE TO THE ABOVE FINANCIAL POLICY

*By submitting your name in this form verifies as your signature

Signature of Patient or Financially Responsible Person*

Date* dd/mm/yyyy

How can we help you?

If you would like to schedule an appointment please use the button below and call one of our locations. If you have any questions or need help with anything else feel free to fill-out our online contact form. Thank you.

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