Podiatry Associates of New Mexico, LTD
PATIENT REGISTRATION FORM
General
Information:
Patient Name: ___________________________________________ Date: __________________
Address: ______________________________________________________________________
Home Phone:_____________________ Work:__________________ Cell:__________________
Email Address: ____________________________________________________________
Marital Status: [ ] Married [ ] Single [ ] Widowed [ ] Divorced [ ] Partnered
Social Security Number: ________-_______-________ DOB: _____________ Sex: M / F
Employment Status: [ ] Employed [ ] Unemployed [ ] Retired [ ] Disabled [ ] Student
Employer: ____________________________________ Occupation: _____________________
Employer Address: _____________________________ Phone: ( ) __________________
Emergency Contact Name: _______________________________________________________
Contact Address: _______________________________________________________________
Contact
Phone #: ( )
____________________________ Relationship:_________________
Billing
& Insurance Information:
(Please indicate which one is
applicable)
[ ] I have insurance,
please file my insurance in the order listed below.
[ ] I do not have
insurance and will be responsible for all charges on my account.
[ ] I do not have
insurance and the guarantor listed below will be responsible for all charges to
my account.
[ ] This is a Workers
Comp issue (Please fill out Workers Comp Information section).
Primary Insurance Name:
_______________________________________________________________________
Policy# _____________ ______________________________ Group
#: __________________________________
Policy Holder Name: ______________________________________________
DOB: _______________________
Policy Holder Address:
_________________________________________________________________________
Policy Holder Phone: ( ) ____________________________ Relationship: ___________________________
Secondary Insurance Name:
_____________________________________________________________________
Policy# _____________ ______________________________
Group #: __________________________________
Policy Holder Name: ________________________________________________
DOB: _____________________
Policy Holder Address:
_________________________________________________________________________
Policy Holder Phone: ( ) ____________________________ Relationship: ___________________________
Guarantor
Information:
Guarantor Name: ___________________________________________________
DOB: ____________________
Guarantor Address:
____________________________________________________________________________
Guarantor Phone#: ( ) ______________________________ Relationship: ___________________________
Workers
Compensation Information:
Is your workers comp claim in litigation? [ ] Yes [ ] No If yes, please notify the receptionist.
Date of Accident: _______/______/_______ Place of Accident:
_____________________________________State:_________
Employer at the time of injury:
________________________________________ Phone: _______________________________
Address: ______________________________________________________
City/State/Zip:____________________________
Insurance Company:
_____________________________________________________________________________________
Address:
______________________________________________________ City/State/Zip:____________________________
Claim Number:
_________________________________________________________________________________________
Has a report been filed by your employer? [ ] Yes
[ ] No If yes, when: ___________________________________________
Has a report been filed by your employer? [ ] Yes [ ] No If yes, when: ___________________________________________
Podiatry Associates of New Mexico,
§ Payments for
co-pays, deductibles and non-covered services are due at the time of service,
unless other arrangements have been made in advance with our billing staff.
§ Insurance
balances are billed to patient on receipt of notice from your insurance carrier
and are due in 30 days from the date billed from Podiatry Associates of New
Mexico, LTD.
§ Any balance over 30 days will incur a monthly $10 re-billing
charge. This charge will be added to the
balance due, monthly, until payment is received in full.
§
Balances over 60 days, patients will be
contacted by telephone by one of our billing staff for payment settlement.
§ Balances
over 90 days will be turned over to our collection agency and a fee for
collection will be added to the account.
The collection fee is $75 or 20% of collection balance, whichever is
greater.
§ Any account over 120 days is considered delinquent.
§ Delinquent
accounts will result in discharge from this practice. If this is to occur, you will
be notified by regular and certified mail that you have 30
days to find alternative podiatric
care. During that
30-day period, our physician will only be able to treat you on an
emergency basis.
___________________________________________________________ ________________________________
Patient/Responsible Party Signature
Date
Assignment,
Release and Acknowledgement:
I, the undersigned certify that I (or my dependent)
have insurance coverage with the above mentioned insurance company, and assign
directly to Podiatry Associates of New Mexico, Ltd. (PANM), 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 payment of
benefits to be made to the physician rendering services. I also understand that I will be held
responsible for any costs, which are not covered by my insurance carrier,
including any deductible, co-insurance, co-pay, denial, or any uncovered
services. I understand that if I am
examined by a physician who does not participate with my insurance, I will
receive payment directly from the insurance carrier. I understand fully that it is my responsibility
to sign over all payments, including the Explanation of Benefits (EOB), to the
examining provider. I hereby authorize
PANM to release all the information necessary to secure the payment of
benefits. I authorize the use of this
signature on all insurance submissions.
I understand I am fully responsible for all fees incurred for service(s)
rendered including collection agencies and attorney's fees. I also understand if I do not have insurance
coverage all fees incurred for service(s) rendered are due at the time of
service. I understand the payment
policies as outlined above.
___________________________________________________________ ________________________________
Patient/Responsible Party Signature Date
Medicare
Authorization:
I request that payment of authorized Medicare benefits
be made to PANM for any services furnished to me by PANM. I authorize the
release of information about me or any information needed to determine benefits
or the benefits payable for related services to the Health Care Financing
Administration and its agents. I understand my signature requests that payment
be made and authorizes release of medical information necessary to pay the
claim. If another health insurance is indicated, or electronically submits
claims, my signature authorizes release of the information to the insurer or
agency shown. In Medicare assigned cases, the physician or supplier agrees to
accept the charge determination of the Medicare carrier as the full charge and
the patient is responsible only for the deductible, coinsurance and non-covered
services. Coinsurance and the deductible are based upon the charge
determination of the Medicare carrier.
___________________________________________________________ ________________________________
Patient/Responsible Party Signature Date
Consent:
I hereby consent to be routinely treated by the doctors
of Podiatry Associates of New Mexico LTD, who are deemed necessary to evaluate
and/or treat foot and ankle injuries for myself or the patient mentioned above
for who I am responsible. I acknowledge
that no guarantees have been made as to the nature of examination and/or
procedures recommended or performed. If
further diagnostic testing is required, it is my decision whether to proceed
with the testing recommended after it has been fully explained to me by the
physician.
___________________________________________________________ ________________________________
Patient/Responsible Party Signature
Date
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 Polaroids, digital,
35mm slide, standard photographs, videotapes, etc. These photographs are PANM's
property and will be a permanent part of the record. These may be used for teaching, lectures,
educational conferences, or publications.
___________________________________________________________ ________________________________
Patient/Responsible Party Signature
Date