Kentucky Foot Professionals
(Formerly Bryant Podiatry)
Patient Information
Patient Name: ______SSN: ______-______-______
Home Address: ______
City ______ZIP:______
Home # ______Cell#______Work# ______
E-Mail Address______How did you hear about our office______
Primary Physician: ______Phone Number______
Pharmacy Info. ______Phone Number______
Date of Birth: ______Sex: Male or Female
Primary Insurance: ______Insurance ID# ______
Secondary Insurance: ______# ______
Other Insurance: ______#______
Emergency Contact: ______#______
______
Signature of Patient Date
FILL OUT IF INFORMATION IS DIFFERENT THAN PATIENT
Guarantor Name: ______
SSN# ______-______-______Date of Birth: ______
I understand and agree that (regardless of my insurance), I am ultimately responsible for the balance of my account for any professional services rendered. I have read all the information on both sides of this sheet and have completed the above answers. I certify this information is true and correct to the best of my knowledge I
will notify you of any changes in my status or the above information.
______
Parent/Guardian Signature (If Patient is a minor) Date
Kentucky Foot Professionals
Insurance Questionnaire
Patient: ______
Employer: ______
Insurance Carrier: ______
ID#:______Group#______
I hereby instruct and direct______Insurance Company to pay by check made out and mailed to:
Kentucky Foot Professionals
2130 Nicholasville Road, Ste #1
Lexington, Ky 40503
Or
If my current policy prohibits direct payment to the doctor, I hereby also instruct and direct you to make out the check to me and mail it as follows:
For the professional or medical expense benefits allowable, and otherwise payable to me under my current insurance policy as payment toward the total charges for the professional services rendered. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above mentioned assignee, and I have agreed to pay, in a current manner, any balance of said professional service charges over and above this insurance payment.
A photocopy of this assignment shall be considered as effective and valid as the original.
I also authorize the release of any information pertinent to my case to the insurance company, adjuster or attorney involved in the case.
I authorize the doctor to initiate a complaint to the Insurance Commissioner for any reason on my behalf.
Signature: ______Date:______
Witnessed: ______