PATIENT INFORMATION



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: ❏ M ❏ F Single:___ Married:___ Widowed:___ Divorced:___

Employer: ________________________________________________ Work Phone: __________________________

May we call you at work? ❏Y ❏ 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:____________________

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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? ❏Y ❏ N Are you pregnant? ❏Y ❏ N

Are you in good general health? ❏Y ❏ N If no, explain: __________________________________________________

Please check if you have had any of the following:

❏ Swelling of feet/ankles ❏ Tired feet ❏ Broken bone in foot/ankle ❏ Eye trouble

❏ Lower Back Pain ❏ Asthma ❏ Diabetes ❏ Cramps/Numbness in feet or legs

❏ Heart trouble ❏ Epilepsy/Seizures ❏ Kidney Disease ❏ Neuropathy

❏ Liver trouble ❏ Hepatitis ❏ Vascular Issues ❏ High blood pressure

❏ HIV/AIDS ❏ Arthritis ❏ Bleeding disorder ❏ 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 today’s standards. If there is any change in my medical status, I will inform the doctor.

Signature: ______________________________________________________________________ Date______________

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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

I understand that my secondary claim is billed as courtesy only and will be submitted to the appropriate party

ONE TIME. 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___________________________

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