Page 1Patient Registration Form

PAGE 1PATIENT REGISTRATION FORM

DATE: ____/______/______DR. FREDERICK N. FEDORCHAK, F.A.C.F.A.S.

IS YOUR VISIT DUE TO A JOB RELATED INJURY OR AUTO ACCIDENT? ⃝ Yes ⃝ NoIF YES, PLEASE NOTIFY THE RECEPTIONIST, THANKYOU!

REFERRING PHYSICIAN: ______

If not referred by another physician, why did you choose this clinic? ⃝ Yellow pages ⃝ Website⃝ Previous patient ⃝ Insurance List ⃝Friend ⃝ Family ⃝ Other: ______

PATIENT NAME: (FIRST) ______(LAST) ______(MIDDLE INITIAL) __

SEX: ⃝F ⃝ MDATE OF BIRTH: ______AGE: ____ (CHECK ONE)Married___ Single___ Divorced __ Separated _____Widowed_____HEIGHT: ____WEIGHT: ____SHOE SIZE: ____WIDE___ NARROW ___ AVG____

HOME PHONE: (____) ______CELL PHONE:(____) ______WORK PHONE: (____) ______

HOME ADDRESS: ______

(STREET) (CITY) (STATE) (ZIP)

SOCIAL SEC. # ______EMAIL ADDRESS: ______

Would you be interested in having communications sent to you via your e-mail address? ⃝ YES ⃝ NO

(Examples: administrative updates, health bulletins, reminders, etc.)

PATIENT’S EMPLOYER: ______OCCUPATION: ______

EMPLOYER’S ADDRESS (Street, City, State, and Zip): ______⃝ FULL TIME ⃝ PART TIME

COLLEGE STUDENTS:CHECK ONE: FULL TIME____ PART TIME____ College Name: ______

PRIMARY CARE PHYSICIAN: ______Phone: ______

PRIMARY PHARMACY: ______LOCATION AND PHONE # (if known) ______

PERSON RESPONSIBLE FOR BILL: (COMPLETE ONLY IF DIFFERENT THAN THE PATIENT)

Name: ______Social Security Number: ______

(Relationship to Patient):CHECK ONE: Spouse ____ Parent ____ Other ______Date of Birth: ___ /___ /___HomePhone: ______Cell Phone: ______

Street Address: ______City: ______State: ______Zip: ______

Responsible Party’s Employer: ______

Employer’sPhone Number: ______Employer’s Street Address: ______

(City) ______(State) ______(Zip Code) ______

WHO TO CALL FOR AN EMERGENCY: Name: ______ADDRESS: ______

PrimaryPhone: (____) ______Work Phone: (____) ______Relationship to patient:______

PAGE 2INSURANCE INFORMATION

PATIENT NAME: ______Date: ______

PRIMARY INS. PLAN

Plan Name: ______ID# ______GROUP# ______

Policy Holder: ______Policy Holder’s Date of Birth: ___/___/______Social Security # ______Patient’s relationship to Policy Holder: ⃝SELF ⃝ SPOUSE ⃝ SON OR DAUGHTER⃝OTHER RELATIONSHIP: ______

Employer of Policy Holder: ______

ADDRESS OF EMPLOYER: ______

(STREET) (CITY) (STATE) (ZIP)

SECONDARY INS. PLAN

Plan Name: ______ID# ______GROUP# ______

Employer of Policy Holder: ______

ADDRESS OF EMPLOYER: ______

(STREET) (CITY) (STATE) (ZIP)

THIRD INS. PLAN

Plan Name: ______ID# ______GROUP# ______

Employer of Policy Holder: ______

ADDRESS OF EMPLOYER: ______

(STREET) (CITY) (STATE) (ZIP)

⃝ I CERTIFY THAT THE ABOVE INSURANCE INFORMATION IS CORRECT

INSURANCE AUTHORIZATIONI hereby authorize the processing of the medical insurance either by electronic or manual method by the provider listed below. My signature authorizes payment of all major medical and/or surgical benefits to which I am entitled from my insurer to pay the below listed provider assignee. I further authorize the assignee to release all medical and/or insurance claim information necessary to secure the payment(s). I recognize my financial obligation of any co-insurance or deductible and non-covered services that may be required. This agreement will remain in effect until revoked by me in writing. A copy of this document is considered as valid as an original.

PROVIDER: DR. FREDERICK N. FEDORCHAK, F.A.C.F.A.S. ● 3215 WILLOWCREEK RD● PORTAGE, IN 46368

X Signature: ______Relationship to Patient: ______DATE: ______

PAGE 3 ERISA*/FINANCIAL POLICY PATIENT: ______DATE: ______

⃝I CERTIFY THAT I HAVE READ AND UNDERSTAND THE ERISA ASSIGNMENT* BELOW:

*I assign the right to payment for all medical benefits directly to Dr. Frederick N. Fedorchak in consideration for medical services and supplies provided pursuant to my health insurance plan. In the event my health insurance plan refuses to pay for provided, medically necessary services, I also assign all of my ERISA* rights to Dr. F. N. Fedorchak for a full and fair review of any and all denied claims. This ERISA*assignment is in consideration for the unpaid services provided and in consideration for the continued willingness of Dr. F. N. Fedorchak to see patients, including myself, on an insurance assignment basis. I understand that if my treating doctor prevails in any such dispute, I may be liable for co-payment for the contested services. I give consent to release medical information to Dr. F. N. Fedorchak. I give consent to Dr. F. N. Fedorchak to release medical information to other healthcare providers for the purpose of treatment, when necessary for my care. I give consent to Dr. F. N. Fedorchak to send medical information, as necessary, to my insurance plan. I acknowledge that I am financially responsible for payment whether or not covered by insurance. *ERISA is an acronym for the Employee Retirement Income Security Act. The Employee Retirement Income Security Act includes federal laws requiring insurance companies to process submitted insurance claims and appealed (denied) insurance claims according to ERISA regulations. The failure to process submitted insurance claims and appealed (denied) insurance claims according to ERISA regulations can and may result in fines charged to the insurance company in amounts of up to $110 a day for each infraction.

X Signature: ______Relationship to Patient: ______DATE: ______

FINANCIAL POLICY AND AGREEMENT

PLEASE READ CAREFULLY AND SIGN

Dr. Frederick N. Fedorchak is a Surgeon, Board Certified in Foot and Ankle Reconstructive Surgery. Dr. Fedorchak’s charges will be determined by the nature and difficulty of the services rendered. However, in no event will the charges be less than the Usual and Customary as defined by Blue Cross/Blue Shield.All procedures performed by Dr. Fedorchak for which insurance can be billed will be done so promptly. Payment not received in 90 days becomes your immediate responsibility. Our office is not responsible for an insurance company’s delay in payment, or for an insurance company’s determination as to how much of Dr. Fedorchak’s charges they will pay. All charges not paid by insurance must be paid by you within 120 days of the date of the service or the account will be turned over to our attorney for collection. In the event of collection, you will be responsible for payment of reasonable attorney’s fees and court costs incurred, and further agree that any lawsuit filed against you seeking collection of a delinquent account balance shall be fined in Porter County, Indiana, regardless of your county of residence. Our payment policy is necessary so that we can continue to provide a high quality of care, and your cooperation is greatly appreciated. All office visit insurance co-pays are expected to be paid for on the date of service. If you have any questions or concerns regarding your account, please do not hesitate to call our office and speak to our billing staff.All x-rays taken in this office are the property of Dr. Frederick Fedorchak. A fee is charged for our digital x-rays to be copied and taken out of this office.

⃝I HAVE READ AND UNDERSTAND THE FINANCIAL POLICY ABOVE AND AGREE TO ALL THE TERMS AND CONDITIONS STATED. X SIGNATURE: ______DATE: ______

PRINTED SIGNATURE: ______RELATIONSHIP TO PATIENT: ______

PAGE 4HIPPA

DR. FREDERICK N. FEDORCHAK, F.A.C.F.A.S.

PATIENT: ______DATE: ______

HIPPA: HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT

With the enactment of the Health Insurance Portability and Accountability Act of 1996; Dr. Frederick N. Fedorchak recognizes that a patient has the right to have his/her health information kept private and secure. As part of Dr. Fedorchak’s Quality Assurance Plan, we may find it necessary, at times, to call your home to leave a message with a person or a message on a recorder for you to call us. Please check all that apply:

_____ I grant permission for Dr. Frederick N. Fedorchak’s office to contact me at my home regarding information that they might need for my care. They may also leave a message with a person at my home and/or leave a message on a recorder.

_____ Yes, you may call but speak only with me (the patient). Do not leave a message.

_____ I prefer that you contact me only at the following phone number(s) provided: ______

⃝ I acknowledge that I have been provided with a copy of the HIPPA PRIVACY PRACTICES to read, and I have been offered a copy to keep, if I so choose. I give my permission for the below listed persons to obtain, to receive, or to inquire about all medical information pertaining to me.

NAME: ______RELATIONSHIP TO PATIENT: ______

X Signature: ______Relationship to Patient: ______DATE: ______

PAGE 5MEDICAL HISTORYPATIENT: ______DATE:______

ALCOHOL USE:□NEVER□ 1 to 2 times per year □1 to 2 times per month □ 1 to 2 times per week

TOBACCO USE: □ Current Smoker □ Never □ Past Smoker; NOT NOW

SUBSTANCE ABUSE:□ NEVER□ YES, SOMETIMES □ YES, IN THE PAST

PHYSICAL EXERCISE:□NEVER □ 1-2 times/week □ 3-4 times/week □ 5-6 times/week □ Daily

RATE CONDITION OF HEALTH: CHECK ONE: EXCELLENT____ GOOD____ FAIR ____ POOR ____

ARE YOU SUBJECT TO PROLONGED BLEEDING? □ YES□NO

REVIEW OF SYSTEMS: (PLEASE REVIEW CHART BELOW AND CHECK THE BOXES THAT APPLY TO ANY HEALTH

CONDITIONS THAT YOU MAY HAVE)

HEART
□Coronary Artery Disease
□Hypertension
□High Cholesterol
□Heart Murmur
□Mitral Valve Prolapse
□High Blood Pressure
□Palpitations/Fluttering of Heart / MUSCULOSKELETAL
□Osteoarthritis
□Osteoporosis / RESPIRATORY
□Asthma
□Emphysema
□Shortness of Breath
/ ENDOCRINE
□Thyroid Disease
□Diabetes 1 or 2
NEURO
□NUMBNESS/TINGLING
□Seizure Disorder
□Tremors
□Stroke
□Other: ______/ VASCULAR
□Phlebitis
□Clotting/ Bleeding Problems
□Enlarged veins in legs
□Leg cramps while walking or at
night / HEENT
□Blurry Vision
□Hearing Loss
□Ringing in Ears / URINARY
□Blood in Urine
□Kidney Stones
SKIN
□Rash □MRSA
□Psoriasis / GASTROINTESTINAL\ DIGESTIVE
□REFLUX □Peptic Ulcer
□Hepatitis□Liver Disease / PSYCHIATRIC
□Anxiety
□Depression / GENERAL
□Cancer ______
□Redness/Heat of any joint? ______
□Fever□Chills □HIV/AIDS
□HISTORY OF GOUT

PAGE 6 MEDICATIONS/SURGERY HISTORY

PATIENT: ______DATE: ______

MAIN FOOT PROBLEM: ______

OTHER PROBLEMS WITH YOUR FEET OR LEGS: ______

FILL IN YOUR CURRENT MEDICATIONS IN THE CHART BELOW. PLEASE INCLUDE PRESCRIPTIONS, OVER THE COUNTER MEDS., VITAMINS, OR SUPPLEMENTS. IF YOU HAVE A LIST, OUR STAFF WOULD BE HAPPY TO COPY IT FOR YOUR CHART.

MEDICATION NAME / STRENGTH (IF KNOWN) / DOSING (HOW OFTEN?)

Are you taking any of the following medications?

□Birth Control □ Aspirin therapy □ Sedatives □Hormone Replacement Therapy/ Injections

PLEASE CHECK THE BOX NEXT TO ANY SURGERY YOU HAVE HAD AND ENTER THE DATE, IF KNOWN

SURGERY / DATE
□APPENDECTOMY
□BIOPSY INCISION TYPE: ______
□TONSILLECTOMY
□HERNIA REPAIR TYPE: ______
□KIDNEY STONE
□LAPAROSCOPY
□LUMPECTOMY TYPE: ______
□BREAST BIOPSY AND RELATED SURGERIES
□CHOLECYSTECTOMY (GALL BLADDER REMOVED)
□COLON SURGERY
□CESAREAN SECTION
□CORONARY ARTERY BYPASS
□HYSTERECTOMY COMPLETE_____ PARTIAL _____
□JOINT REPLACEMENT TYPE: ______
□SURGICAL REPAIR OF BONE:(Details): ______
□UPPER GI ENDOSCOPY
□LOWER GI ENDOSCOPY
□STOMACH SURGERY TYPE: ______
□DEBRIDEMENT OF: WOUND ____ BURN____ INFECTION ____
□ANKLE SURGERY: LEFT ____ RIGHT _____ BOTH _____
□KNEE REPLACEMENT:LEFT ____ RIGHT _____ BOTH _____
□FOOT SURGERY: TYPE: ______
□OTHER: ______

PAGE 7 HEALTH HISTORY/ALLERGIES PATIENT: ______DATE: ______

Please list ANY additional problems or health conditions you are PRESENTLY BEING TREATED FOR: ______

______

Have you ever been hospitalized for any illness? ⃝Yes ⃝ No If yes, please explain: ______

______

Have you had a tetanus injection in the last 7 years?⃝Yes ⃝ No

Have you ever had steroid treatment?⃝Yes ⃝ No If yes, when? ______

ALLERGIES

PLEASE CHECK ALL THAT APPLY:

⃝ PENICILLIN ⃝ ERYTHROMYCIN⃝ SULFA⃝ NOVOCAIN⃝ MERTHIOLATE

⃝ MERCUROCHROME

⃝IODINE (SEAFOOD) ⃝ TETANUS ANTITOXINS OR SERUMS ⃝ NAIL POLISH

⃝ ADHESIVE TAPE

⃝ CODEINE ⃝ MORPHINE ⃝ COSMETIC ⃝STEROIDS

PLEASE LIST ALL OTHER DRUG OR ANTIBIOTIC ALLERGIES OR SENSITIVITIES:______

______

⃝I CERTIFY THAT ALL MEDICAL INFORMATION I HAVE PROVIDED IS CORRECT.

X______PRINTED: ______DATE:______

(Signature of patient or authorized representative RELATIONSHIP TO PATIENT: ______

DR. FREDERICK N. FEDORCHAK, F.A.C.F.A.S BOARD CERTIFIED PODIATRIC PHYSICIAN AND SURGEON

3215 WILLOWCREEK ROAD DIPLOMAT, AMERICAN BOARD OF PODIATRIC SURGERY

PORTAGE, IN 46368 FELLOW, AMERICAN COLLEGE OF FOOT AND ANKLE SURGEONS

PATIENT NAME: ______DATE: ______

OFFICE POLICIES

1. Insurance / Proof of Insurance.We participate in most insurance plans, including Medicare. If you are not insured by a planwe do business with, payment in full is expected at each visit. Please contact your insurance company with any questions you may have regarding your coverage. All patients must provide their insurance card(s) to the Receptionist at the time of check-in.

2. Referrals, Co-payments and Deductibles.Referrals must be presented at the time of service. All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Your appointment will be rescheduled if any of these items are not available at time of service. A receipt can be provided for all payments at the check-out desk.

3. Non-Covered Services.Please be aware that some – and perhaps all – of the services you receive may be noncovered or not considered reasonable or necessary by Medicare or other insurers.

4. Coverage changes. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. If you fail to provide us with the correct insurance information or notify us of changes in insurance in a timely manner, you may be responsible for the balance of a claim.

5. Claims submission.We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim.

6. Prescription Refills/Renewals.Please do not wait until your prescription runs out or has expired. Allow 72 hours notice to review your refill or renewal request. Refill and/or renewal requests will only be processed Monday through Thurs.during normal business hours. Written pain medication (narcotic) prescriptions must be picked up in the office and will not be refilled after hours, or on weekends.

7. Appointments.We greatly appreciate you allowing us to provide thebest care possible. Our physician and staff know your time is important and we hope you understand the value of our time. We want to be able to provide every patient with all the attention they require. Therefore, if you are not on time for your appointment and are late 30 minutes or more, it may be necessary to reschedule for another day. Please provide us with 24 hour notice if you will not be able to maintain your appointment.

□I have read and understand the above and agree to abide by its guidelines. (A copy will be provided to you upon request.)

X______PRINTED: ______DATE:______

(Signature of patient or authorized representative) RELATIONSHIP TO PATIENT: ______

Please let us know if you have any questions or concerns.