Dawn Y. Stein, DPM, CWS, LLC
Patient Information
Name:
LastFirstMiddle
Address:
StreetCity State Zip
Home#: Work#: Mobile#:
Preferred Contact Phone#:E-mail:
Age: DOB:/ / SS#: - - Sex: □M □F Lives Alone: □Yes □No
Primary Physician: Phone#: Last Visit:
Pharmacy: Phone#: Fax:
Marital Status: □Single □Married □Divorced □Widowed □Separated Occupation:
Spouse’s Name: Spouse’s Preferred Phone#:
Emergency Contact:
Name PhoneRelationship
If under age 18, guardian’s name:Guardian’s address (if different):
PRIMARY INSURANCE:Member ID/Policy#:
SS# of
Group #: Insurance Phone#:Insured:
DOB of
Insured’s Name:Insured: / /
LastFirst Middle
Insured’s Address:
StreetCity State Zip
SECONDARY INSURANCE:Member ID/Policy#:
Group #: Insurance Phone#:
WORKER’S COMPENSATION Insurance Company:Claim #:
Mailing Address:Phone#:
Date of Accident: Agent’s Name: Agent’s Phone #:
Name of Employer:Supervisor’s Name/Phone:
Brief Description of Accident:
Patient Medical History
Patient Name:DOB:Date:
Height: Weight:Shoe Size:
Reason for today’s visit:
Past Medical History:
AIDS/HIV□Yes □NoDiabetes□Yes □NoOsteoporosis□Yes □No
AnestheticAllergy□Yes □NoEar Problems□Yes □NoPeripheral arterial dis.□Yes □No
Alzheimers/dementia□Yes □NoEpilepsy□Yes □NoPhlebitis□Yes □No
Anemia□Yes □NoEye Problems□Yes □NoPsychiatric disorder□Yes □No
Arthritis□Yes □NoFainting□Yes □NoRadiation □Yes □No
Artificial Heart□Yes □NoGout□Yes □NoRash□Yes □No
Artificial Joint□Yes □NoHeadaches□Yes □NoRespiratory dis.□Yes □No
Asthma□Yes □NoHeart Disease□Yes □NoRheumatic Fever□Yes □No
Back Problems□Yes □NoHemophilia□Yes □NoShortness of breath□Yes □No
Bleeding Disorder□Yes □NoHepatitis/Jaundice□Yes □NoSinus Problems□Yes □No
Blood Clots□Yes □NoHigh Blood Pressure□Yes □NoSickle Cell Anemia□Yes □No
Cancer□Yes □NoKidney Disease□Yes □NoSkin ulcers□Yes □No
Chemical dependency□Yes □NoLiver Disease□Yes □NoStomach ulcer□Yes □No
Chest Pain□Yes □NoLow Blood Pressure□Yes □NoStroke□Yes □No
Chronic Diarrhea□Yes □NoMitral Valve Prolapse□Yes □NoSwelling legs/feet□Yes □No
Circulatory Problems□Yes □NoNervous Problems□Yes □NoTuberculosis□Yes □No
Varicose Veins□Yes □NoNeuropathy□Yes □NoThyroid disease□Yes □No
Any other relevant medical information we should know?
Previous Surgeries/Hospitalizations:When?Hospital, City, State
Medications:
Medication / Dosage / Frequency / Reason / Medication / Dosage / Frequency / ReasonAllergies:□ No Known Drug Allergies
Adhesive Tape □Yes □NoDemerol □Yes □NoLocal Anesthetic□Yes □NoSulfa □Yes □No
Antibiotics □Yes □NoIodine □Yes □NoPenicillin□Yes □NoTetanus □Yes □No
Aspirin □Yes □NoLatex □Yes □NoSeafood□Yes □NoVicodin/Codeine □Yes □No
Other:
Social History:
Use of Alcohol: □ Never□ Rarely□ Moderate□ DailyHow Long?
Use of Tobacco:□ Never□ Quit, date □ Currently, Packs a day?Years
Illicit Drug Use:□Yes □NoRehab:□Yes □NoDrug(s):
Currently Pregnant:□Yes □No Number of Child Births
Family History (list medical history of immediate family):
AIDS/HIV□Yes □NoDiabetes□Yes □NoOsteoporosis□Yes □No
AnestheticAllergy□Yes □NoEar Problems□Yes □NoPeripheral arterial dis.□Yes □No
Alzheimers/dementia□Yes □NoEpilepsy□Yes □NoPhlebitis□Yes □No
Anemia□Yes □NoEye Problems□Yes □NoPsychiatric disorder□Yes □No
Arthritis□Yes □NoFainting□Yes □NoRadiation □Yes □No
Artificial Heart□Yes □NoGout□Yes □NoRash□Yes □No
Artificial Joint□Yes □NoHeadaches□Yes □NoRespiratory dis.□Yes □No
Asthma□Yes □NoHeart Disease□Yes □NoRheumatic Fever□Yes □No
Back Problems□Yes □NoHemophilia□Yes □NoShortness of breath□Yes □No
Bleeding Disorder□Yes □NoHepatitis/Jaundice□Yes □NoSinus Problems□Yes □No
Blood Clots□Yes □NoHigh Blood Pressure□Yes □NoSickle Cell Anemia□Yes □No
Cancer□Yes □NoKidney Disease□Yes □NoSkin ulcers□Yes □No
Chemical dependency□Yes □NoLiver Disease□Yes □NoStomach ulcer□Yes □No
Chest Pain□Yes □NoLow Blood Pressure□Yes □NoStroke□Yes □No
Chronic Diarrhea□Yes □NoMitral Valve Prolapse□Yes □NoSwelling legs/feet□Yes □No
Circulatory Problems□Yes □NoNervous Problems□Yes □NoTuberculosis□Yes □No
Varicose Veins□Yes □NoNeuropathy□Yes □NoThyroid disease□Yes □No
Review of Systems (Personal History):
Constitutional Systems / Gastrointestinal / NeurologicalGood general health □Yes □No / Loss of appetite □Yes □No / Frequent headaches □Yes □No
Recent weight change □Yes □No / Nausea/vomiting □Yes □No / Light headedness □Yes □No
Fever □Yes □No / Abdominal pain □Yes □No / Convulsion/seizures □Yes □No
Fatigue □Yes □No / Numbness/tingling □Yes □No
Genitourinary / Tremors □Yes □No
Eyes / Kidney stones □Yes □No / Paralysis □Yes □No
Eye disease/injury □Yes □No / Frequent urination □Yes □No / Head injury □Yes □No
Wear glasses/contacts □Yes □No
Blurred/double vision □Yes □No / Musculoskeletal / Psychiatric
Joint pain □Yes □No / Memory loss □Yes □No
Ear/Nose/Mouth/Throat / Joint stiffness □Yes □No / Confusion □Yes □No
Hearing loss/ringing □Yes □No / Weakness □Yes □No / Nervousness □Yes □No
Swollen glands □Yes □No / Muscle pain □Yes □No / Depression □Yes □No
Leg cramps □Yes □No / Insomnia □Yes □No
Cardiovascular / Back pain □Yes □No
Swelling extremities □Yes □No / Difficulty walking □Yes □No / Hematological/Lymphatic
Chest pain/angina □Yes □No / Slow to heal □Yes □No
Palpitations □Yes □No / Integumentary (skin) / Easy to bruise □Yes □No
Restless legs □Yes □No / Rash/itching □Yes □No / Anemia □Yes □No
Cold extremities □Yes □No / Change in skin color □Yes □No / Phlebitis □Yes □No
Skin ulcer □Yes □No / Previous transfusions □Yes □No
Respiratory / Eczema □Yes □No / Excessive bleeding □Yes □No
Chronic cough □Yes □No / Varicose veins □Yes □No / Enlarged glands □Yes □No
Coughing blood □Yes □No
Wheezing □Yes □No / Endocrine
Shortness of breath □Yes □No / Dry skin □Yes □No
Excessive thirst/urination □Yes □No
Heat/cold intolerance □Yes □No
Dawn Y. Stein, DPM, CWS, LLC
ASSIGNMENT AND RELEASE/CONSENT
I, the undersigned, certify that I (or my dependent) have insurance coverage as noted above and assign directly to Dr. Dawn Y. Stein all medical and surgical benefits, if any, otherwise payable to me for services rendered. I hereby authorize the release of all medical information necessary for the processing of insurance. I understand that I am financially responsible for all charges whether or not paid by insurance. Copies of this agreement are to be considered valid as an original signature. This policy remains in effect unless revoked by me in writing.
Signature of Patient/Insured/Guardian Date
I certify that the information on these forms is true and correct to the best of my knowledge. I give permission to the doctor to administer and perform such procedures as deemed necessary in the diagnosis and/or treatments of my podiatric ailments.
Signature of Patient/Insured/Guardian Date
I permit Dr. Dawn Y Stein to access any medical records via the Grove City Medical Center Electronic System to aid in my treatment and processing of my insurance claim/billing.
Signature of Patient/Insured/Guardian Date
MEDICAL HISTORY ATTESTATION
To the best of my knowledge, my medical history on this form is complete and the questions have been accurately answered. It is my responsibility to inform the doctor’s office of any changes in my medical history, including but not limited to allergies, past medical history, medications, etc.
Signature of Patient, Parent, or GuardianDate
Dawn Y. Stein, DPM, CWS, LLC
Office Financial Policy
(Effective January 1, 2013)
We welcome you to the office of Dr. Dawn Y. Stein and appreciate you choosing usfor your podiatric needs. It is the policy of Dawn Y Stein, DPM, CWS, LLC to provide the best possible foot and ankle care and to make our services available to as many patients as possible. In order to provide this service, we have established a written financial policy that is mutually beneficial to all parties. It is our goal to avoid any misunderstandings or concerns regarding the financial policy. Please read and sign the following policy:
- To keep medical care and billing costs down, payment for services is required in full at the time services are rendered. This includes co-pays, deductibles, non-covered services, co-insurances, and any services/additional fees deemed not payable by your insurance company. We will bill your insurance company for services performed; you will be responsible for the remaining difference. Payment arrangements are available upon request and with prior approval by our office. The following company will process all insurance claims/billing for Dawn Y. Stein, DPM, CWS, LLC:
Dawn Y. Stein, DPM, CWS, LLC
P.O. Box 16008
Pittsburgh, PA 15242
412.920.1111
- Medicare and some health insurance companies select certain services that they will not cover; payment for these services is your responsibility. Your health insurance policy is a contract between you and your insurance company. It is encouraged that you fully understand your insurance policy and the conditions of your coverage.
- We are contract providers for Medicare and many private insurance plans. Our fees are considered usual, customary and reasonable (UCR), therefore allowing for maximum coverage by the insurance company. Our accepting assignment of your insurance benefits does not relieve you of your personal responsibility for timely payment of the total bill. If your insurance company does not completely or promptly pay, you are responsible for the remaining balance.
- If it is required by your insurance company to have a referral or authorization to see Dawn Y. Stein, DPM, CWS, LLC you must obtain the referral/authorization prior to the visit or you will be financial responsible for the services provided.
- For a patient under the age of 18, a parent, guardian or legal representative must accompany the patient during each service and will be responsible for all payments incurred.
- We will be glad to issue you a receipt that you can forward to your insurance company and/or for personal use.
- If it is determined that you did not present the correct insurance identification card at the time of service, you will be responsible for the charges incurred if denied by your insurance company.
- If your treatment involves other entities such as hospitals, laboratories, rehabilitation facilities, etc., you will billed separately.
- There will be a $35.00 fee for a returned check issued to Dawn Y. Stein, DPM, CWS, LLC.
- Original medical documents and x-rays are part of your permanent medical record and will not be released. Copies of your medical record are available upon request in writing. A minimum of two weeks is required to receive copies of your medical records. A $25 fee will be associated with the compiling and copying of your file.
- A fee may be assessed for the completion of any disability forms, personal credit life insurance forms, attending physician statements, letters of medical necessity or other miscellaneous forms.
- We understand financial problems may arise. If such problems affect timely payment, we encourage you to contact us immediately for assistance in the management of your account.
Patient Authorization
I certify that I have insurance with the company(ies) disclosed and assign directly to Dawn Y. Stein, DPM, CWS, LLC all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am responsible for all charges whether or not they are paid by my insurance. I authorize the use of my signature on all insurance claims.
Medicare/Medigap Authorization
I request that payment of authorized Medicare benefits, and if applicable, Medigap benefits be made either to me or my behalf to Dawn Y. Stein, DPM, CWS, LLC for all services rendered.
My signature signifies that I have read and fully understand this Financial Policy and agree to abide by all its terms.
Signature of Patient/Guardian Date
Dawn Y. Stein, DPM, CWS, LLC
Welcome to our office and thank you for coming. Dawn Y. Stein, DPM, CWS, LLC is pleased to have you as a new patient and are looking forward to taking care of your podiatric needs.
Please let us know how you heard about our practice so we can continue to expand our services to the community. Thank you for your time!
(Please check all that apply)
□ 1. My physician referred me.
□ 2. My family member/friend suggested your practice.
□ 3. The Emergency Room referred me.
□ 4. The local hospital recommended me.
□ 5. My health insurance company recommended Dawn Y. Stein, DPM, CWS, LLC for my podiatry needs.
□ 6. I learned about Dawn Y. Stein, DPM, CWS, LLC from the “media”:
□ Allied Newspaper
□ The Eagle newspaper
□ The Herald newspaper
□ Phone Book
□ Radio ads
□ Educational lecture
□ Community organization
□ Internet
□ Website
□ Social Media (facebook, twitter, etc.)
□ Post card
□ 7. Other
Comments: ______
Dawn Y. Stein, DPM, CWS, AACFAS
Doctor of Podiatric Medicine, Certified Wound Specialist,
Associate, American College of Foot & Ankle Surgeons
15 Woodland Center Drive, Grove City, PA 16127 p: 724-458-6245 f: 724-458-6244
224 West Mahoning Avenue, Punxsutawney, PA 15767 p: 814-938-1770 f: 814-938-1771
Medical Information Release Form
(HIPAA Release Form)
Name: ______Date of Birth: _____/____/_____
Release of Information
[ ] I authorize the release of information including the diagnosis, records;
examination rendered to me and claims information. This information may be released
to:
[ ] Spouse______
[ ] Child(ren)______
[ ] Other______
[ ] Information is not to be released to anyone.
This Release of Information will remain in effect until terminated by me in writing.
Messages
Please call [ ] my home [ ] my work [ ] my cell Number:______
If unable to reach me:
[ ] you may leave a detailed message
[ ] please leave a message asking me to return your call
[ ] ______
The best time to reach me is (day)______between (time)______
Signed: ______Date: ____/____/_____
Witness:______Date: ___/____/______
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