Podiatry Intake Form | Podiatrist, Foot Doctor Lake City, FL 32055 and Branford, FL 32008

Please complete the following form and answer all questions before arriving for your appointment.

Be sure to include your insurance information.
We'll see you soon!

Patient Information

First name (*)

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Middle Initial

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Last name (*)

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Your Email Address (Responsible Party) (*)

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Mailing Address (*)

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City (*)

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State (*)

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Zip-Code (*)

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Phone number (*)

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Date of Birth: Month (*)

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Day (*)

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Year (*)

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Sex (*)

Male Female

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Marital Status (*)

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Height (*)

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Weight (*)

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Shoe size (*)

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*This information is requested due to Healthcare Reform laws dictated by Congress.

Ethnicity

Hispanic or Latino Non-Hispanic or Non-Latino Decline to Specify Invalid Input

Preferred Language(*)

English Spanish Other

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Specify

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Are you pregnant?(*)

No Yes Invalid Input

Are you nursing?(*)

No Yes Invalid Input

Have you completed an Advance Directive (living will)? (*)

Yes No

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Primary Care Physician (*)

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Primary Care Physician Address (*)

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Physician Phone Number (*)

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Date last seen: Month

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Day

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Year

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Pharmacy (*)

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Pharmacy Phone (*)

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Who?

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Other

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What helps / makes it worse?

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Is it limiting your activity level? (*)

Yes No

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Secondary problem (if there is one)

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Please list any drug allergies (*)

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List Medications You Take (*)

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Specify other

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If you have cancer, please list type and treatment

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Please list past surgeries and year surgery was performed (*)

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Is your problem related to a Workman’s Comp injury or an auto/other accident?(*)

No Yes

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Current Problem

What specific problem brings you to the office today? (*)

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Where is the pain or problem located? (*)

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How long ago did this problem first start? (*)

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Did your pain or problem: (*)

Begin all of a sudden Gradually develop over time

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Please Describe Your Pain (*)

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Since the time your pain or problem began, it has: (*)

Stayed the same Become worse Improved

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Please describe what makes your pain or problem feel worse? (*)

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What makes your pain or problem feel better? (*)

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What treatments have you had for this problem? (*)

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How has this problem affected your lifestyle or ability to work? (*)

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Was this problem caused by an injury? (*)

Yes No

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If YES, describe: (*)

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Do you smoke, vape or use chewing tobacco?(*)

Never Past Yes

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Please specify

Cigarettes Cigars Chewing Tobacco Vaping Invalid Input

How many per day?

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Method of Quitting

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Do you have/have had a substance abuse problem?(*)

Never Past Yes

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Please specify

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Family History

Which family members had the below medical conditions? (father, mother, sibling, etc.)

Diabetes

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Stroke

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Cancer

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Arthritis

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Heart Attack

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Hypertension/High Blood Pressure

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Insurance Information

Subscriber's Name (*)

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Subscriber's D.O.B. (*)

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Patient's Relation to the Subscriber (*)

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HMO (*)

Yes No

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Primary Insurance (*)

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Policy Number (*)

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Policy Holder Name (*)

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Policy Holder Date of Birth: Month (*)

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Day (*)

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Year (*)

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Secondary Insurance

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Secondary Policy Number

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Occupation (*)

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Employer (*)

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Employer Address

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City

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State

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Zip-Code

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Employer Phone Number

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Emergency Contact

First Name (*)

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Last Name (*)

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Relationship to Patient (*)

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Phone (*)

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Responsible Party (if minor patient)

First Name

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Last Name

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Relationship to Patient

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Date of Birth: Month

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Day

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Year

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View Privacy Policy

All office visit charges and co-pays are due at the time services are rendered. It is the patient who is responsible for any and all financial aspects of services rendered. There will be a charge for returned checks, missed appointments without 24 hours notice and completion of any forms. I agree to pay for all deductibles, co-pays, non-covered services and any portion of covered services not paid in full by my insurance plan and understand that such payments are due at the time of service or immediately upon presentation of the bill. I hereby name SAMERA / Foot + Ankle (SFA) as my assignee. I instruct my health care benefits plan administrator, i.e. PLAN to pay SFA directly for all professional and medical services provided by SFA through the means of electronic funds transfer(s) (EFT) or by check(s) made payable to and mailed to SFA. I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS CLAIMS.

I Agree (*)

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The above information is correct to the best of my knowledge. I understand that throughout my treatment, I am responsible for notifying the physician and/or medical staff of any and all updates to the information listed above. I also give permission for photographs of my feet to be taken that are to be kept as part of my medical record only. They will not be published as part of medical research or disbursed in any way without my permission.

I Agree (*)

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I acknowledge that I was provided a copy of the Notice of Privacy Practices for SAMERA / Foot + Ankle and I have read (or had the opportunity to read if I so choose) and understood the Notice.

PAYMENT RESPONSIBILITIES

We are pleased to welcome you to our office. New Patients are always appreciated. Our practice has grown as a result of its excellent relationship with our referring doctors and patients. As our patient, please feel free, at any time, to express any concerns or to ask any questions that you may have for the doctor or our staff. In order to assist you in making payment(s) for your podiatric treatment, the following options are listed. Please read them carefully and feel free to discuss them with us.

If you DO NOT have insurance: Payment is due, in full, at the time treatment is provided.

*For your convenience, we accept all major credit/debit cards and cash. We accept personal checks for payments under $50.00.

If you have Insurance: The percentage of coverage by your insurance company may be based on your insurance company’s own reduced fee schedule for medical services and may be less than actual charges resulting in lower coverage for you. SAMERA / Foot + Ankle has no control over this situation. Lower payment is a direct result of the plan selected by you or your employer. Please be advised that we cannot waive co-payment. We are required by law to collect co-payment.

Commercial Insurance: We will submit your claim to your insurance carrier for you. You are responsible for any deductible or co-payment not covered by your insurance. Once our office has received payment from the insurance company, you will be billed, with 30 day terms, for any amount still owed. You may choose to keep a credit card on file for those balances left to you by your insurance company.

Medicare: This office accepts Medicare assignment. Medicare patients are fully responsible, however, for the initial yearly deductible and the 20% co-insurance. Federal law requires that physicians collect this amount. If you have a secondary insurance to cover the 20%, we will submit the balance to that insurance for payment and you will only be responsible for the yearly deductible.

FINANCIAL POLICY

CO-PAYS, CO-INSURANCE & DEDUCTIBLES All co-pays are due at the time of your appointments. We accept cash, check, debit and major credit cards.

MEDICAL PROCEDURES MAY NOT BE CONSIDERED “MEDICALLY NECESSARY” Certain procedures and services provided during your medical visit may not be covered by insurance. It is your responsibility to understand that you may be charged fees for procedures that your insurance company may not find “medically necessary.” Some common procedures that insurance companies find “not medically necessary” include toenail trimming and callous debridement without a systemic condition (ie Diabetes mellitus, Renal Disease, anti-coagulant therapy, Neuropathy, etc.).

CANCELLATION OF APPOINTMENTS and NO SHOW FEE SAMERA / FOOT + ANKLE Requires a 24-hour notice for appointment cancellations so that we can offer the appointment to another patient. There is a fee of $30.00 for medical appointments that are missed or cancelled less than 24-hours in advance. Appointments will not be rescheduled until this amount is paid. We call the day before appointments for a reminder (Friday for Monday appointment) and if you are signed up for Patient Fusion you will receive a text or email.

OUTSTANDING BALANCES A medical practice, like any business, depends on timely payments. It is our policy that all accounts remain current. In the event that a patient balance remains outstanding and no resolution can be made, your account may be sent to a collection agency and/or you may be discharged from the practice.

LABORATORY FEES Most laboratory charges, such as cultures, and pathology tests, ordered through our office are billed directly to your insurance by the laboratory processing the test. If you receive a statement from the pathologist laboratory, we request that you contact them directly to resolve any billing issues.

INSURANCE CLAIMS As a courtesy to you, we will submit medical claims to your insurance company. Any balance after processing of the claim by your carrier is your responsibility. Your insurance policy contract is between you and your insurance company. You are responsible for verifying if providers are in network for your insurance company. In order to properly bill your insurance company, we require that you disclose all insurance information. Failure to provide complete insurance information may result in patient responsibility for the entire bill. If your insurance requires referrals to specialists, it is your responsibility to obtain that referral PRIOR to your appointment. Failure to obtain a valid referral may hold you responsible for any payments incurred for services rendered. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility of benefits. If your insurance company is not contracted with our office, you agree to pay any portion of the charges not covered including, but not limited to, those charges above the usual and customary allowance. If we are out of network and your insurance pays you directly, you are responsible for payment in full and agree to forward payment to us immediately.

RETURNS All sales are final on any private pay orthotic devices, creams/medications, shoe gear, stockings, socks, etc.

RETURNED CHECKS There will be a $35.oo fee for all returned checks.

Please sign with your initials (*)

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