Podiatry Associates of New
Mexico,
PATIENT REGISTRATION FORMS
General Information:
Patient Name: ________________________________________________
Date: __________________
DOB: _________________ Sex: M / F Social
Security Number: ________-_______-________
Race: (please circle) American Indian/Alaska Native Asian Black/African American White Other
Race
Native Hawaiian/Pacific
Islander Decline
Ethnicity: (please
circle) Hispanic or Latino NOT Hispanic or Latino
Decline
Preferred Language:
__________________________________________________________________
Marital Status: [ ]
Married [ ] Single [ ] Widowed [ ] Divorced [ ] Other
Address:
___________________________________________________________________________
Home Phone:_____________________
Work:____________________ Cell:_____________________
Email Address:
_____________________________________________________________________
Employment Status:
[ ] Employed [ ] Unemployed [ ] Retired [ ] Disabled [ ] Student
Employer: ____________________________________ Occupation:
___________________________
Employer Address: ___________________________________ Phone: (
) __________________
Emergency Contact
Information:
Emergency Contact Name:
____________________________________________________________
Contact Phone #: (
) ____________________________ Relationship:_____________________
Resposible Party
Information:
Person Responsible for Account:
_______________________________________________________
Relationship to Patient______________________DOB:__________Soc. Sec.
No.________________
Address (if different from patient):
____________________________________________________________________
Billing & Insurance Information:
Primary Insurance name:
_____________________________________________________________________________
Policy# _____________
____________________________________ Group #:
__________________________________
Policy Holder Name:
___________________________ DOB: _________________Relationship:
____________________
Secondary Insurance name:
___________________________________________________________________________
Policy# _____________
____________________________________ Group #:
___________________________________
Policy Holder Name:
___________________________ DOB: _________________Relationship:
_____________________
Other Information:
Preferred Pharmacy
Name: ________________________________Pharmacy Phone#
________________
§ 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.
§ Unpaid Patient 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.
§ 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
Healthcare
Questionnaire
PATIENT NAME:
_________________________________________________ DOB:
__________________
Who Referred You To Our
Office? ___________________________________________________________
Primary Care
Physician: Name:
__________________________________ Last Visit Date:
_____________
Referring
Physician:
Name: ___________________________________ Last Visit Date:
_____________
Podiatry/Foot/Ankle
Complaint:
Why are you here today?
______________________________________________________________________
Where is the problem area? ___________________________________________________________________
How long have you had this problem?
___________________________________________________________
Have you been seen by our
physicians in the past?
No Yes---If yes,
When? ___________________________
Have you been evaluated or treated
for this problem elsewhere?
No Yes-- If yes,
When? _________________and Where?
________________________________________________________
AMBULATION:
[ ]
None [
] Crutches [ ]
PERSONAL MEDICAL
HISTORY: Please Check All That Apply
[ ] AIDS/HIV
[ ]
Congestive Heart Failure
[ ] Hemophilia
[ ] Radiation/Chemo
[ ] Alcoholism
[ ]
Depression
[ ] Hepatitis – A B
C
[ ] Respiratory Disease *
[ ] Allergies/Hay Fever [ ]
Diabetes *
[ ] High Blood Pressure
[ ] Rheumatic Fever
[ ] Alzheimer’s
[ ]
Drug/Chemical Dependency
[ ] High Cholesterol
[ ] Sinus Problems *
[ ] Anemia
[ ]
Ear Problems *
[ ] High Triglycerides
[ ] Skin Problems *
[ ] Arthritis *
[ ]
Eye Problems *
[ ] Kidney/Bladder Problems *
[ ] Sleep Apnea
[ ] Asthma *
[ ]
Fibromyalgia
[ ] Liver Disease *
[ ] Stroke
[ ] Back Problems *
[ ]
Gallbladder Disease
[ ] Low Blood Pressure
[ ] Thyroid Problems *
[ ] Bleeding Disorders * [ ]
GERD/Hiatal Hernia
[ ] Medical Implants *
[ ] Tuberculosis (TB)
[ ] Blood Clots/DVT/PE * [
] GI Ulcers
[ ] Osteopenia
[ ] Varicose Veins
[ ] Cancer *
[
] Gynecological Problems
*
[ ] Osteoporosis
[ ] Venereal Disease *
[ ] Chronic Diarrhea * [ ]
Headaches
[ ] Nervous System Disorder *
[ ] Vertigo
[ ] Circulatory Problems * [
] Heart Disease *
[ ] Psychiatric Care *
[ ] Other: ____________
[ ]
[ ] TB: date ______________ [ ] Other: __________________________________ date
_____________
HOSPITILIZATIONS &
SURGERIES:
Have you been hospitalized or had any surgeries in the past? No
Yes---Please list below
1) ______________________________
Date: _________4) _____________________________ Date:
___________
2) ______________________________
Date: _________5) _____________________________ Date:
___________
3) ______________________________
Date: _________6) _____________________________ Date:
___________
Please
check if no medications are currently being taken. [ ] None
Name of
Medication
Dosage
How often do you
take
1.
_______________________________________
________________
________________________
2.
_______________________________________
________________
________________________
3.
_______________________________________
________________
________________________
4.
_______________________________________
________________
________________________
5.
_______________________________________
________________
________________________
6.
_______________________________________ ________________
________________________
Pharmacy
Address:
______________________________________________________________________
[ ] Iodine [ ] Penicillin [
] Latex [ ] Aspirin [
] Adhesive Tape [ ] Demerol [
] Codeine [ ] Sulfa
[ ] Local Anesthetics
(Novocain) [ ] Seafood [ ] No Known Allergies [ ] Other: ______________
FAMILY HISTORY: Please Check All That Apply
[ ] Heart Disease No
Yes---Relationship: Father Mother Brother Sister Son Daughter
[ ] Cancer
No
Yes---Relationship: Father Mother Brother Sister Son Daughter
[ ] Diabetes
No
Yes---Relationship: Father Mother Brother Sister Son Daughter
[ ] Other: _________________
Relationship: Father Mother Brother Sister Son Daughter
SOCIAL HISTORY:
Marital Status: [ ] Single [ ] Married [ ] Widowed [ ] Divorced [ ] Other
Occupation:
___________________________________________________________________________
Do you participate in any exercise
regimen on a regular basis?
No Yes …If
yes, what type
and how often?
___________________________________________________
Do you currently smoke or chew
tobacco?
No… If no, any past tobacco
use? No Yes ---If
Yes----Year stopped: ______ Years smoked: ______
Yes… If yes, how many/much per day?
____________ Year started: __________
Do you consume any alcohol? No Yes…If yes, how
much and how often? _____________________________
CERTIFICATION:
I certify that the information
provided above is true, correct, and complete to the best of my knowledge,
information, and belief.
_____________________________________________
___________________________________
Signature of Patient or Legal
Guardian
Date
Signed
_____________________________________________
Printed Name of Patient or Legal
Guardian
NOTICE OF PRIVACY
PRACTICES
THIS NOTICE DESCRIBES HOW
MEDICAL/PROTECTED HEALTH INFORMATION ABOUT YOU
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.
If you have any questions or
concerns about this Notice, please contact our Privacy Officer,
at
___________________________________________________________________________________
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."
Please check all that
apply)
[ ] Home Phone
[ ] Home Answering
Machine/Voice Mail
[ ] Cell Phone/Voice
Mail
[ ] Office/Work Place/Voice
Mail
*I authorize my physicians and
his/her staff to communicate information regarding appointments, medical
results, and billing issues to:
(Please print name and indicate your
relationship)
____________________________________________
_____________________________________
Name
Relationship
____________________________________________
_____________________________________
Name
Relationship
____________________________________________
_____________________________________
Name
Relationship
X___________________________________________
_____________________________________
Patient or Representative
Signature
Date
[ ] Patient refused to sign [ ] Patient was unable to sign
because________________________________