Asheville Podiatry Associates, P.A.
Patient Last Name ______ First ______Middle _____
Mailing Address ______
City ______ State ______Zip Code ______
Home Telephone ______Cell______Work ______
E-mail Address ______
Date of Birth ______Age ______Sex M or F Marital Status (circle) S M W D P
Race (circle) African American American Indian Caucasian Asian Other Declined
Ethnicity ( circle) Hispanic Non-Hispanic
How did you hear about our office?: Physician Patient Internet Ad Other ______
Employer ______ Occupation ______
Preferred Pharmacy and Address ______
Primary Insurance ______Secondary Insurance ______
Who carries the Insurance (subscriber)? (circle) Self Child Spouse Partner Other ______
Name Of Subscriber ______Subscriber DOB ______
Subscriber SSN ______Subscriber Employer ______
If someone else (other than the patient or the patient is a minor) is responsible for the patient bill, please complete:
Responsible Party Name ______ DOB ______
Responsible Party Address ______
Responsible Party Telephone # ______
Please Note: All Copay and un-met deductibles are due at the time of service. It is the patient / guardian's responsibility to know and understand their individual health insurance coverage.
X______Date______
Signature of patient, parent/guardian or POA
Asheville Podiatry Associates, P.A.
Name:______Date: ______
Complaint: ______
How long has this been bothering you? ____ Days _____Weeks ____Months ____Years
Please CIRCLE the answers to the questions below.
Did the problem start: gradually or suddenly?
Is the problem: worsening, improving or staying the same?
What type of pain are you having? Sharp, dull, aching, throbbing, burning, numbness, tingling
Is the pain: constant or intermittent?
Is the problem worse with: weight bearing, non-weight bearing or both?
What previous treatment have you received for this problem?
Medication (which one)______,
Different shoes.padding, shoe inserts, rest, surgery,
Other treatment ______.
Did these treatments help? Yes/ No.
Name of primary care physician(s)______
Last seen by physician______
Review of Systems:
Constitutional Respiratory Musculoskeletal Cardiovascular
___Fever ___Cough ___Foot/leg injuries ___ Chest pain
___Weakness ___Wheezing ___Joint pain/stiffness ___ Palpitations
___Fatigue ___Shortness of breath ___Back pain/neck pain ___ Poor circulation
___Weight gain ___Sleep apnea ___Unequal leg length ___ Fainting
___Weight loss ___Snoring ___Muscle Cramps ___ Varicose Veins
___Loss of appetite ___Lung Disease ___Falls ___ DVT
___Asthma ___Osteoporosis ___High blood pressure
___Heart Problems
Endocrine Skin Neurological Immune System
___High blood sugar ___Dryness ___Abnormal balance ___Frequent infections
___Low blood sugar ___Itching ___Numbness ___Chemotherapy
___Frequent urination ___Skin Lesions ___Headache ___High dose steroid
___Excessive thirst ___Scars ___Tingling ___ Transplant
___Diabetes ___Rash ___Restless leg ___ AIDS
___Thyroid problems ___Stroke ___ Lupus
___Cold/Heat intolerance ___ Cancer
Gastrointestinal Blood/Lymph
___Nausea ___Bleeding tendency
___Vomiting ___Bruising tendency
___Diarrhea ___Anemia
___Heart burn ___Liver disease
___Stomach problems ___Kidney disease
___Stomach ulcer ___Hepatitis OVER
Social History
Use of Alcohol... ____ Never ____Rarely ___Moderate ____Daily
Use of Tobacco... ____ Never ____ Previously, but quit ____ Packs per day
Use of Drugs.... ____ Never
Family History: Any relatives with similar foot problems? Yes / No What relation? ______
Please list all surgeries (tonsillectomy, appendectomy, etc.)
______
______
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______
Please list all medications including prescription and over the counter vitamins, minerals and supplements:
Name of medicine Dosage
______
______
______
______
______
______
Medication Allergies Yes / No ______
______
Height: ______Weight: ______
Shoe Size: ______
Asheville Podiatry Associates, P.A.
Thank you for choosing Asheville Podiatry Associates for your foot and ankle care. Please understand that payment of your bill is ultimately your responsibility. The following is a statement of our Financial Policy which we require you to read and sign prior to any treatment.
•Full payment is due at time of service for all self-pay, co-pays, deductibles, non-covered services and supplies. The Guardian/Adult accompanying a minor is responsible for any payment due at time of service.
Our Office Accepts Cash, Check, and ALL major Debit/Credit Cards
Regarding your Insurance
Accurate insurance information must be given at the time of service; otherwise we cannot bill your insurance carrier. Your insurance coverage is a contract between the subscriber, and the insurance company. If your insurance company has not paid your account within 45 days of treatment, the balance will be transferred to you. We will do our best to verify coverage and provide you with an estimate of what is covered. You are responsible to know your benefits; including copays, deductibles, and non-covered services. We do not guarantee coverage by your insurance carrier for any services or supplies. We will file your charges to your primary insurance carrier and to your secondary insurance only if we are contracted with them. We do not file tertiary insurances.
No Show Appointments
If a current patient does not show up for a scheduled appointment or cancels an appointment without 24 hours notice, our policy is to charge $30.00 per visit. ______
Please Initial
Billing
We are not a billing service. As a courtesy to our patients the first bill mailed to you for an account balance is free. A billing service fee may be charged for each additional bill mailed from our office. Accounts over 90 days may be sent to a collection agency.
Record Requests and Disability Forms
Original medical records and x-rays are the property of Asheville Podiatry Associates. We will be glad to make copies of your records for a nominal fee. All disability and FMLA forms must have the patient portion of the form completed in full and all associated fees paid prior to completion. Please allow 7-10 days for completion of record requests and disability forms. ALL requests must include; a signed authorization for release of information, and addressed, stamped envelope if you are not picking them up.
I authorize release of any information concerning: me, my child, and or the individual for whom I am the responsible party, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I also authorize payment of insurance benefits, not paid by myself, directly to Asheville Podiatry Associates.
I have read and agree to the above Financial Policy of Asheville Podiatry Associates:
Signature of Patient or Responsible Party (Guardian, POA)Date
OVER
Asheville Podiatry Associates, P.A.
Request for Confidential Communications and Patient Acknowledgment of Receipt of Notice of
Privacy Practices "HIPPA"
I request Appointment Reminder Calls be made in one of the Following Ways:
Telephone voice message to the following telephone number ______
Text messages to the following telephone number ______
E-mail to the following address ______
I prefer not to receive reminder calls ______
I request that all other communications to me be Asheville Podiatry Associates and /or staff be handled in the following manner:
Leave message on home answering machine Yes ___ No ___
Leave message with person(s) answering my home telephone Yes ___ No ___
Leave message on my cellular telephone Yes ___ No ___
Emergency Contact: Name______Phone #______
I authorize the following individual(s) to receive communication and information regarding my health care:
______
______
I acknowledge that upon request that I am entitled to a copy of Notice of Privacy Practices and that I have read or had the opportunity to read if I so choose, and understand the notice.
______
Print Name of Patient or Guardian Date
______
Signature of Patient or Guardian Date
05/01/18