Access Wound Care and Podiatry Care

New Patient Information Form

* Required fields

  
PATIENT INFORMATION INSURANCE
Name:*
Address:*
City:*
Zip:*
Phone number:*
Sex:*
Male Female
Birthdate:*
mm/dd/yyyy
Marital status:*
S M W D
Patient SS#:*
Occupation:*
Employer:*
Employer phone:*
Spouse name:
In case of emergency contact:*
Phone:*
Relationship:*
Patient email:
Medicare:
Medi-Cal:
Issue date:
Are you under an HMO plan?
yes no
Do you have an authorization
form PCP?
yes no
Medicare Supplement Insurance:

Company:
Phone:
ID#:
Group:
Private Insurance:
Name of company:
Phone:
ID#:
Group:
Subscriber name:
DOB:
Relationship to patient:
Is patient covered by other
insurance?
Assignment and release:
I hereby give my permission to Dr. or his associates
to administer treatment as may be deemed necessary in the treatment
and diagnosis of my foot and or ankle complaints, and I hereby authorize my insurance company to pay benefits directly to Dr..
I understand that I am financially responsible for all non-covered services. I also authorize Dr. to release any information required to bill the insurance company for me. I also authorize the use of this signature on all insurance submissions.
Responsible party:
Relationship:
Date:
Medicare authorization:
I request that payment of authorized Medicare benefits be made on my behalf
to Dr for any services furnished me by the listed provider. I authorize any holder of medical information about me to release
to the NHIC and its agents any information needed to determine these benefits or the benefits payable to related services. I understand my signature below request that payment be made and authorizes release of medical information necessary to pay the claim. If other health insurance is indicated in item 9
of the HCFA-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the provider or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, co-insurance, and non-covered services. Co-insurance ant the deductible are based upon the charge determination of the Medicare carrier
Beneficiary name:
Date:
FAMILY PHYSICIAN
Name:
Address:
Phone:
Date of last appointment:
What is the chief complaint for which you wish to be treated?
Is this a work related injury?
yes no
Automobile injury?
yes no
Date of injury:
Referred to our office by:

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