Patient Demographic Information and Financial Release
Patient Information
First Name
MI
Last Name
Preferred Name (if different)
Date of Birth
Age
Responsible Party
(if minor)
Gender
M
F
Marital Status
Married
Single
Divorced
Widowed
Spouse Name
Address
City
State
Zip
Address Type
Home
Relative
Other
Phone
(please also check preferred contact number)
Home
Cell
Work
Email Address
Social Security No.
Primary Language
Race
African American
American Indian
Caucasian
Chinese
Filipino
Hispanic
Japanese
Multiracial
Native American
Declined
Ethnicity
Hispanic or Latino
Non-Hispanic or Latino
Declined
Employed by
Occupation
Work Address
City
State
Zip
Referred by
Emergency Contact Name
Phone
Relationship
Insurance Information
Do you have healthcare insurance?
Yes
No
Primary Insurance Company
Policy No.
Group No.
Is the Patient the Subscriber?
Yes
No
Subscriber Name
Date of Birth
Social Security No.
Relationship to Patient
Employer Name
Do you have secondary healthcare insurance?
Yes
No
Secondary Insurance Company
Policy No.
Group No.
Subscriber Name
Date of Birth
Social Security No.
Relationship to Patient
Employer Name
Is the billing address different than the patient's home address?
Yes
No
Address
City
State
Zip
I hereby authorize the release of any medical and billing information necessary to process payment for claims and request benefits to be mailed directly to the physician until I revoke said authorization in writing. I understand that I (and spouse if married, or parent if minor) assume responsibility for payments of amounts due for services rendered and above the amount covered by insurance or the total amount, if I do not have applicable insurance coverage. My signature below guarantees my assumption of responsibility to the amount owed pursuant to this agreement.
Signature of Patient or Legal Guardian
– Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date
Medical History
Patient Information
Patient Name
Date of Birth
Height
Weight
Shoe Size
Blood Pressure (if known)
Family Physician Name
Phone
Last Visit
Pharmacy Name
Pharmacy Phone
Pharmacy Address
City
State
Zip
Foot Care Information
What foot problems brought you to our office today?
How long has this bothered you?
Have you injured your foot?
Yes
No
How and When?
List any previous foot care/foot surgeries that were not listed above.
Personal Information
Do you smoke?
Yes
No
How much?
Do you drink alcohol?
Yes
No
How much?
Do you use illegal drugs?
Yes
No
What kind?
How much?
Are you pregnant?
Yes
No
How many months?
Have you had surgeries?
Yes
No
List type and date
Current Medications
Please list type, dosage and reason for taking (include over-the-counter medications as well as herbal supplements)
Add another medication?
Add another medication?
Add another medication?
Add another medication?
Add another medication?
Add another medication?
Add another medication?
Add another medication?
Add another medication?
Medication Allergies
(list type of medication and reaction)
Add another allergy?
Add another allergy?
Add another allergy?
Medical Conditions
Please indicate if you currently have or had any of the following, along with the approximate date of onset:
Anemia
Arthritis
Bleeding Tendency
Circulation
Diabetes
Fainting/Convulsions
Gout
HayFever/Asthma
Heart Problems
High Blood Pressure
HIV Positive/AIDS
Kidney Disease
Liver Disease
Low Back Pain
Numbness in Feet/Legs
Psychiatric
Scarring Tendency
Skin
Stomach/Digestive
Strokes
Thyroid
Flu Vaccine
Pneumonia Vaccine
Do you have other conditions not listed above?
Yes
No
Please describe
Authorization for Release of Information
Compound Release
Patient Name
Date of Birth
Heartland Podiatry, PC
is authorized to release protected health information about the above named patient in the following manner and to identified persons.
May we leave a voice mail for you that includes sensitive information?
Yes
No
Please list the phone number where a message may be left
May we discuss your information with others such as a Spouse or Parent?
Yes
No
Please provide name and phone number below and select applicable box(es) to the right
Financial
Medical
Financial
Medical
Financial
Medical
May we send you information via email?
Yes
No
I understand that if information is not sent in an encrypted manner there is a risk it could be accessed inappropriately. I still elect to receive email communication as selected.
Email Address
Information Type
Financial
Medical
Appointment Reminders
Breach Notification
May we send you information via text message?
Yes
No
I understand that if information is not sent in an encrypted manner there is a risk it could be accessed inappropriately. I still elect to receive text message communication as selected.
Phone No.
Information Type
Appointment Reminders
Other
May we use photos received by you?
Yes
No
How may we use them? Select applicable box(es) below
Post in office
Post on website
Other
With prior verbal notification, may we take photos of you?
Yes
No
Example: Pre/Post Procedure. How may we use them? Select applicable box (es) below.)
Post in office
Post on website
Other
Patient Rights:
I have the right to revoke this authorization at any time.
I may inspect or copy the protected health information to be disclosed as described in this document.
Revocation is not effective in cases where the information has already been disclosed but will be effective going forward.
Information used or disclosed as a result of this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law.
I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing.
This authorization will remain in effect until revoked by the patient.
Signature of Patient or Personal Representative
– Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date
Relationship of Personal Representative to Patient
Acknowledgement of Receipt of Notice of Privacy Practices
*** You May Refuse to Sign this Acknowledgement ***
I,
have received a copy of Heartland Podiatry, PC's Notice of Privacy Practices.
Address
City
State
Zip
Signature of Patient or Personal Representative
– Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date
Relationship of Personal Representative to Patient