Bluegrass Regional Foot and Ankle Associates

Bluegrass Regional Foot and Ankle Associates

WELCOME TO OUR OFFICE

Patient Information

Name______Circle One: Male/Female

First Middle Last

Address ______City ______State_____ Zip______

Home Phone (___) ____-______Cell (___) ____-_____ Work(___) ___-_____

Age_____ Date of Birth ___/___/___ SS# _____-_____-______

Email Address:______

List your Family DR/NP/PA:______LAST DATE SEEN?______

Which Pharmacy do you use:______

(Please Circle Answers Below)

Primary Race: WhiteBlack Hispanic Other:______

Language: English Spanish Other:______

Marital Status: Single Married Widowed Divorced

Employer:______Occupation:______

Parent / Spouse’s Name:______

EMERGENCY CONTACT

Name:______Relationship:______

Phone: (____)____-______Alternate Phone: (____)_____-______

WHOM MAY WE THANK FOR REFFERING YOU?

Doctor / Nurse Practitioner / Physician Assistant: ______

Friend / Relative: ______Other: ______

Bluegrass Regional Foot and Ankle Associates

Podiatric and Medical History

What is your foot/ankle problem?______

______

Which foot/ankle is it? (Circle one) RIGHT LEFT BOTH

Where on your foot/ankle does your problem exist?______

______

How long have you had your problem?______

______

Has your problem gotten worse, better, or stayed the same?______

Does anything make your problem worse?______

______

Have you had any treatments for your problem?______

______

Is there anything else you would like to tell us concerning your problem?______

______

Allergies: Do you have any drug allergies? YES NO

Do you have any seasonal/environmental allergies? YES NO

Do you have any food allergies? YES NO

I am allergic to: Penicillin Sulfa Aspirin Cephalosporins Erythromycin LATEX

Iodine Adhesive Tape Novocaine/Lidocaine

OTHER Drug Allergies:______

List of Food or Environmental allergies:______

Past Medical History: (CIRCLE YOUR Personal Medical History)

Aids/HIV Alcoholism Appendicitis Asthma Cancer Diabetes Emphysema Gout MS Hepatitis High Blood Pressure Pacemaker Pneumonia Seizures Stroke Ulcer Thyroid Disorder OTHER: ______

Past Surgical History: (CIRCLE YOUR Personal Surgical History)

Amputation of (toe) (foot) (leg) Angioplasty Ankle Surgery Appendectomy Back Surgery

C-Section Eye Surgery Foot Surgery Hip Replacement Knee Surgery Nail Removal Thyroid Surgery Tonsillectomy Heart Surgery Vascular Surgery Wisdom tooth removal

OTHER: ______

Family History: (CIRCLE your Blood Related Relatives Medical History)

Cancer Depression Diabetes Genetic Disease Heart Disease High Cholesterol Stroke

High Blood Pressure Rheumatoid Arthritis OTHER:______

Social History: Smoking/Tobacco Use Alcohol Use-____drinks per week Illegal Drug Use

Review of Systems: (CIRCLE Conditions/Problems that you CURRENTLY have)

Constitutional: Anxiety Dizziness Fever Headaches Nausea/Vomiting Increased Thirst

Tiredness Vertigo Weight Gain Weight Loss

Cardiovascular: Ankle Swelling Cramp in Calf Cardiovascular Problems Cold Feet

Murmur Elevated BP Pacemaker Varicose Veins

Endocrine: Dry Hair Dry Skin Extreme Thirst Unusual Fatigue

ENT: Cough Difficulty Hearing Difficulty Swallowing Dry Mouth

Eyes: Wear Glasses Blurred Vision Dry Eyes Loss of Vision

GI: Blood in stool Constipation Diarrhea Heartburn (GERD) Hemorrhoids Vomiting

Rectal Bleeding Yellowing of Skin

Genitourinary: Kidney Disease Currently Pregnant Urinary Frequency

Immunologic: Arthritic Flare-up Gout Attack Hepatitis Seasonal Allergies

Skin: Athlete’s Foot Blisters Burning of Skin Dermatitis Dry, Scaly Skin Itchy Rash

Leg Ulcer Non-Healing Wounds Rash Tingling Sensation

Lymphatic: Calf Pain Legs Swelling Water Retention

MSK: Back Pain Weakness in Legs Heel Pain Hip Pain Joint Swelling Leg Cramps

Morning Stiffness Muscle Tenderness

Neurological: Burning in feet Numbness Paralysis Seizures Tingling

Psychiatric: Addiction- Alcohol Addiction- Drugs Anxiousness Depression Memory Loss

Panic Attacks Emotional/Psychiatric difficulties

Respiratory: Difficulty Breathing Shortness of Breath Wheezing

Rx & OTC Medications Dosage How many times a day

1)______once twice three other:

2)______once twice three other:

3)______once twice three other:

4)______once twice three other:

5)______once twice three other:

6)______once twice three other:

7)______once twice three other:

8)______once twice three other:

9)______once twice three other:

10)______once twice three other:

Please list any other important medical information here:

SECTION 1.

INSURANCE INFORMATION

ASSIGNMENT AND RELEASE

I, the undersigned, certify that I (or my dependent) have insurance coverage with ______and assign directly to Bluegrass Regional Foot and Ankle Associates, PSC (BRFAA) 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 my insurance. I hereby authorize BRFAA to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

Insurance Provider______Policy No.______

Policy Subscriber information (*if other than patient)

Name ______Relationship to Patient ______Date of Birth ___/___/____

Address ______Employer ______

SECTION 2.

MEDICARE AUTHORIZATION (If Applicable)

I request that payment of authorized Medicare benefits be made either to me or on my behalf to Bluegrass Regional Foot & Ankle Associates, PSC (BRFAA) for any services furnished me by this group. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. I request payment of authorized Medigap benefits be made to this provider an also authorize any holder of medical information about me to release to the below named Medigap insurer any information needed to determine benefits payable for services from this provider. I understand my signature request that payment be made and authorized releases of medical information necessary to pay the claim. If “other health insurance” is indicated in item 9 of the HCFA-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorized releasing of the information to the insurer of agency shown. In Medicare assigned cases, the supplier 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.

By signing below the patient and/or patient guardian acknowledges they have read and understand sections 1 and 2 (if applicable) above.

______

Patient/Guardian Signature Date

Medical Records / Privacy

At Bluegrass Regional Foot & Ankle Associates, we are committed to protecting the security and privacy of your personal information. Medical records are the property of Bluegrass Regional Foot & Ankle Associates, kept in a secure location, and are accessed for only purposes outlined by the Notice of Privacy Practices.Records may be released or shared with other health care providers for your treatment. Patients are entitled to one free copy of their medical records only after an authorization for release is signed. Additional copies may be made for a fee.

• I understand that Bluegrass Regional Foot & Ankle Associates may call my home and place of employment for health care reasons, appointment reminders, to resolve billing issues, and mail informational postcards to my home as well as billing information requested verbally by me.
• I understand that Bluegrass Regional Foot & Ankle Associates may leave messages on my answering machine regarding appointments and limited lab information, and that my email may also be used for these purposes.

I acknowledge that Bluegrass Regional Foot & Ankle Associates will upon request make available a copy of the Notice of Privacy Practices and Consent to Treat Information. I understand that I can edit any of the above items.

Please list any other person(s) that we may release your medical information to.

______

BRFAA Provider Policy

Bluegrass Regional Foot and Ankle Associates (BRFAA) was established in January 2003 by Paul K.Krestik, DPM and Daniel C. Albertson, ARNP. Dr.Krestik is a graduate of Scholl Podiatry School and completed a surgical residency in Massachusetts. Daniel Albertson, a Certified Family Nurse Practitioner, received his Masters Degree from the University of Kentucky in 2000 and has been practicing exclusively in Podiatric Medicine since that time. In the course of your treatment with BRFAA, you may see either: Dr. Krestik or Daniel Albertson. If you have a preference of provider, please notify our office staff and we will make every effort to accommodate your preference.

I acknowledge that I have read and understand the information in sections 1 and 2. I further acknowledge that if I have questions or concerns about BRFAA’s provider policy it is my responsibility to discuss this with a representative of BRFAA.______

Patient/Guardian Signature Date

Bluegrass Regional Foot and Ankle Associates

Payment Obligation Form

It is the policy of Bluegrass Regional Foot and Ankle Associates that all co-payment, co-insurance, supply purchases and/or other patient obligations are to be paid on the date of service being rendered. Please note that any missed appointment without a phone call to our office to cancel or reschedule is subject to a $25.00 “No Show” Fee.

Your insurance requires a:

___ Co-pay of $______per visit.

___ Co-Insurance of ______%. We ask that you pay $______per visit toward your responsibility.

___ Multiple Insurance Carriers:

You will be responsible for any outstanding balance after the processing of claims by your insurance carriers.

___ Claim submission:

Your insurance requires claims to be submitted prior to patient payment. After claims are expedited, if there is a patient balance, you will be billed at that time.

____ Self-pay/No insurance

I agree to pay for services rendered today.

____I have not met my deductible and I agree to pay in full for services rendered today. (Amt. due will be based on your insurance’s allowable fee schedule)

All unpaid balances will be subject to a 12% interest rate.

This information has been explained to me and I fully understand and agree with this payment obligation.

______

Patient/Guardian Signature Date

Due to OSHA (Occupational Safety and Health Administration) and CDC (Center for Disease Control) guidelines, we are required to have all new and established patients fill out the following form annually.

Full Name: ______

Address: ______

Phone #: ______Date of Birth: ______

Have you ever had a positive TB test? Yes No

If yes, when? ______Date of last chest X-ray: ______

To your knowledge, do you currently have TB? Yes No

To your knowledge, have you come in contact with any persons who have had TB

within the last 30 days? Yes No

Please indicate if you have had any of the following problems for 3 to 4 weeks or longer:
Chronic Cough: / Yes No
Production of Sputum: / Yes No
Blood Streaked Sputum: / Yes No
Unexplained Weight Loss: / Yes No
Fever: / Yes No
Fatigue/Tiredness: / Yes No
Night Sweats: / Yes No
Shortness of Breath: / Yes No

I understand that due to OSHA and CDC guidelines, if I have or may have TB, BRFAA has the obligation to refer me to the Health Department and will not be able to see me until I provide proof of a negative TB test.

I understand that I will be given a surgical mask to wear and quarantined until I have transportation to the Health Department. I understand that it is my responsibility to notify BRFAA of any changes in my health regarding TB.

______

Signature DateBottom of Form

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