ࡱ> WYVq  Tbjbjzz Zefef!884tr4eee;======$Haie%@eeeae ;e;t̫o'0oeeeeeeeaaeeeeeeeeeeeeeeee8X :  Welcome to Coastal Carolina Podiatry We are pleased to welcome you to our office! Please take a few minutes to complete these forms. If you have questions we will be glad to help you. Last Name:____________________ First Name: __________________ Middle Initial: _____ DOB: ______/______/______ SSN:______________________________ Address:_________________________________________________________ City:___________________ State: ___ Zip:_____ Primary Phone:___________________ Cell Phone:___________________ Email address:___________________________________ Sex: O' M O' F Single:___ Married:___ Widowed:___ Divorced:___ Employer: ________________________________________________ Work Phone: __________________________ May we call you at work? O'Y O' N Who can we notify in case of Emergency: ____________________________ Relationship to patient: ______________________ Primary Phone: ___________________ Alt Phone: ___________________ INSURANCE INFORMATION (If no card is available to copy) Primary Insurance Insurance Company:__________________________________________ Phone #:__________________________ Contract #: _________________________ Group #: _____________________ Subscriber #:__________________ Person responsible for account: ______________________________________________ DOB:_____/_____/_____ Relation to patient: ________________________ SSN:_____________________ Primary phone:_______________________ Address (if different from patient):__________________________________________________________________________ Insured's employer: __________________________________ Occupation:________________________________________ Business Address: _________________________________________ Business phone: ______________________________ Additional Insurance Is patient cover by additional insurance? _____Yes _____ No Secondary Insurance Company: _____________________________________ Phone #________________________ Contract #:_________________________ Group #: _____________________ Subscriber #:_____________________ Person responsible for account:______________________________________________ DOB _____/_____/_____ Relation to patient:________________________ SSN:_____________________ Primary phone:________________________ Tertiary Insurance Company:__________________________________________ Phone #:______________________ Contract #:_________________________ Group #:_____________________ Subscriber #:_____________________ Person responsible for account:______________________________________________ DOB: _____/_____/_____ Relation to patient: ________________________ SSN:_____________________ Primary phone:____________________  Next page TIENT Patient's Name: ________________________ Medical History Family Physician Name/Phone #: _________________________________ Last Visit: ______________________ Ht: ____ Wt: ____ Last blood pressure count: ____/____ What is the nature of your foot problem?_______________ _____________________________________________________________________________________________ Do you use tobacco products? O'Y O' N Are you pregnant? O'Y O' N Are you in good general health? O'Y O' N If no, explain: __________________________________________________ Please check if you have had any of the following: O' Swelling of feet/ankles O' Tired feet O' Broken bone in foot/ankle O' Eye trouble O' Lower Back Pain O' Asthma O' Diabetes O' Cramps/Numbness in feet or legs O' Heart trouble O' Epilepsy/Seizures O' Kidney Disease O' Neuropathy O' Liver trouble O' Hepatitis O' Vascular Issues O' High blood pressure O' HIV/AIDS O' Arthritis O' Bleeding disorder O' Other: ____________________ ________________________________________________________________________________________________ Please list all allergies: __ NKDA __ Medications:___________________________________________________________________________________ __ Materials: _____________________________________________________________________________________ __ Foods:________________________________________________________________________________________ __ Other: ________________________________________________________________________________________ Please list all prescriptions and over the counter medications that you are currently taking: ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Please list any surgeries you have had: ______________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Authorization The information provided here is true to the best of my knowledge. I understand that this information will be used by the doctor to help determine an appropriate treatment. I authorize my physician to prescribe medication and to give me reasonable and proper medical care by todays standards. If there is any change in my medical status, I will inform the doctor. Signature: ______________________________________________________________________ Date______________  Next Page PATIENT AGREEMENT I understand that payment is due at the time of service, including co-pays and/or deductible. I authorize my insurance company to pay the doctor or medical group all insurance benefits otherwise payable to me for services rendered. I authorize the use of this information on all insurance submissions. I authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the release of information including medical information to this organization and all insurance organizations involved with my claim. I understand that if I am in default of payment, I will be responsible for any attorney or collections fees. Signature:_________________________________________ Date:_____________________________________ ACKNOWLEDGE OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read (or had the opportunity to read if I so chose) and understand the Notice. _____________________________________________ ___________________________________ Patient Name (please print) Date ________________________________________ ________________________________ Parent/Guardian (if applicable) Signature MEDICARE LIFETIME SIGNATURE ON FILE I request that payment of authorized Medicare benefits be made either to me or on my behalf to Coastal Carolina Podiatry for any services provided to me by the physicians. 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 benefits payable for related services. Signature:_________________________________________ Date:_____________________________________ MEDICARE- SECONDARY INSURANCE  %&2RS_    ǶtbMbMbbM?h[-CJOJQJ^JaJ)hXh?B*CJOJQJ^JaJph#hXB*CJOJQJ^JaJph!hXh?B*OJQJ^Jphh?OJQJ^Jh[-h~OJQJ^Jh[-hXOJQJ^Jh[-h?OJQJ^J h[-5>*CJ(OJQJ^JaJ(&h[-hE5>*CJ(OJQJ^JaJ(&h[-h?5>*CJ(OJQJ^JaJ( h O5>*CJ(OJQJ^JaJ(&S*  < Z %p$dha$dhgd[-dhgdXdh$a$gdX $ P &a$gd O     $ % ) * . M O V W y    \ f l n p r ӾӰӟ򾍾v-hXh?B*CJOJPJQJ^JaJph#hXB*CJOJQJ^JaJph hXhHCJOJQJ^JaJhOCJOJQJ^JaJ)hXh?B*CJOJQJ^JaJph hXh?CJOJQJ^JaJh[-CJOJQJ^JaJhXCJOJQJ^JaJ)r t x z | ~ X Z ֿ뮠vhWhEֿֿ#hdB*CJOJQJ^JaJph hdhdCJOJQJ^JaJhdCJOJQJ^JaJh?CJOJQJ^JaJh[-CJOJQJ^JaJhXCJOJQJ^JaJhOCJOJQJ^JaJ hXh?CJOJQJ^JaJ-hXh?B*CJOJPJQJ^JaJph)hXh?B*CJOJQJ^JaJph'h[-B*CJOJPJQJ^JaJph   ; < U l t y { > ? 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After that one time submission if the insurance company does not pay within 60 days or denies the claim, I (the patient) will be financially responsible to pay. Signature:_________________________________________ Date:_____________________________________ Discussion of medical treatment Patient Name: _____________________________________ Date_________________________ List the family members or other person, if any, whom we can discuss you medical condition and your diagnosis to. (Your social security Number must be known to this person in order for them to access confidential information) Name:_____________________________ Relationship to you___________________________ Name:_____________________________ Relationship to you___________________________ Name:_____________________________ Relationship to you___________________________ Name:_____________________________ Relationship to you___________________________ QQQQRR(SzSSTT T d7$8$H$7$8$H$ $7$8$H$a$ QQQRRRS(SzSSTTT Th?6CJOJQJh?CJOJQJh[-h?CJOJQJ^J > 00P:pX/ =!"h#$% Dp8 00P/ =!"h#$% Dp8 00P/ =!"h#h$% Dpy666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@666666_HmH nH sH tH @`@ NormalCJ_HaJmH sH tH DA D Default Paragraph FontViV 0 Table Normal :V 44 la (k ( 0No List PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vj\{cp/IDg6wZ0s=Dĵw %;r,qlEآyDQ"Q,=c8B,!gxMD&铁M./SAe^QשF½|SˌDإbj|E7C<bʼNpr8fnߧFrI.{1fVԅ$21(t}kJV1/ ÚQL×07#]fVIhcMZ6/Hߏ bW`Gv Ts'BCt!LQ#JxݴyJ] C:= ċ(tRQ;^e1/-/A_Y)^6(p[_&N}njzb\->;nVb*.7p]M|MMM# ud9c47=iV7̪~㦓ødfÕ 5j z'^9J{rJЃ3Ax| FU9…i3Q/B)LʾRPx)04N O'> agYeHj*kblC=hPW!alfpX OAXl:XVZbr Zy4Sw3?WӊhPxzSq]y i h!Z@ZzZ r `"|%'Q T !#$&,TU&Q T"%+8@6(  J    #" ?J    #" ?B S  ?n h!D%F+Yt4&+t!  !!  !!XQ O ~OhK)[-IF O7O{Y0>^ K?xdEFS]8} _7H6D!!@d !@ @8@@Unknown G.[x Times New Roman5Symbol3. .Cx Arialc  ZapfDingbatsArial Unicode MS]AGaramond-SemiboldCambriaK=   jMS Gothic-3 0000C.,*{$ Calibri Light7.*{$ CalibriA$BCambria Math"hUzUzz==!20!!3HX $PH2!xx PATIENT INFORMATION Kim Hatchett Kim Hatchett Oh+'0  8 D P \hpxPATIENT INFORMATIONKim HatchettNormalKim Hatchett2Microsoft Office Word@@5@&x@&x ՜.+,0 hp   Microsoft=! 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