Intake Form

Please complete the following form and answer all questions before arriving for your appointment.

Be sure to include your insurance information.
We'll see you soon!

Patient Information

First name (*)

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Middle Initial

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Last name (*)

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Your Email Address (Responsible Party) (*)

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Mailing Address (*)

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City (*)

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State (*)

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Zip-Code (*)

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Phone number (*)

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Date of Birth: Month (*)

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Day (*)

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Year (*)

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Sex (*)

Male Female

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Marital Status (*)

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Height (*)

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Weight (*)

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Shoe size (*)

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Race (*)

*This information is requested due to Healthcare Reform laws dictated by Congress.

Ethnicity

Hispanic or Latino Non-Hispanic or Non-Latino Decline to Specify Invalid Input

Preferred Language (*)

English Spanish Other

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Specify

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Are you pregnant? (*)

No Yes Invalid Input

Are you nursing? (*)

No Yes Invalid Input

Have you completed an Advance Directive (living will)? (*)

Yes No

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Primary Care Physician (*)

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Primary Care Physician Address (*)

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Physician Phone Number (*)

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Date last seen: Month

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Day

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Year

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Pharmacy (*)

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Pharmacy Phone (*)

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Who?

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Other

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Primary Reason for Visit (*)

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Duration of Condition (*)

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What helps / makes it worse?

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Is it limiting your activity level? (*)

Yes No

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Secondary problem (if there is one)

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Please list any drug allergies (*)

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List Medications You Take (*)

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Specify other

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If you have cancer, please list type and treatment

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Please list past surgeries and year surgery was performed (*)

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Is your problem related to a Workman’s Comp injury or an auto/other accident? (*)

No Yes

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Review of Systems

Please check if you have any of the following symptoms:

Eyes:

Change of vision Blurred vision Cataracts Eyeglasses Invalid Input

Ear:

Hearing aid Infections Ringing Invalid Input

Nose:

Bleeding Discharge Infection Invalid Input

Mouth:

Bleeding Post nasal drip Dentures Dry mouth Invalid Input

Throat:

Hoarseness Tenderness Lumps Sore throat Invalid Input

Respiratory:

Shortness of breath Persistent coughing Wheezing Invalid Input

Renal System:

Painful urination Increased frequency Decreased frequency Blood in urine Invalid Input

Psychiatric:

Depression Mood swings Sleep disturbance Invalid Input

Allergies:

Sneezing Watery or itchy eyes Hives Invalid Input

If you checked any of above, please explain:

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Do you drink alcohol? (*)

Never Past Yes

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How often?

Daily 1-2 x Week 1-2 x Month 1-2 x Year Invalid Input

Do you smoke, vape or use chewing tobacco? (*)

Never Past Yes

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Please specify

Cigarettes Cigars Chewing Tobacco Vaping Invalid Input

How many per day?

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Method of Quitting

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Do you have/have had a substance abuse problem? (*)

Never Past Yes

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Please specify

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Family History

Which family members had the below medical conditions? (father, mother, sibling, etc.)

Diabetes

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Stroke

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Cancer

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Arthritis

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Heart Attack

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Hypertension/High Blood Pressure

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Insurance Information

Subscriber's Name (*)

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Subscriber's D.O.B. (*)

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Patient's Relation to the Subscriber (*)

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HMO (*)

Yes No

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Primary Insurance (*)

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Policy Number (*)

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Policy Holder Name (*)

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Policy Holder Date of Birth: Month (*)

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Day (*)

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Year (*)

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Secondary Insurance

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Secondary Policy Number

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Occupation (*)

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Employer (*)

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Employer Address

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City

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State

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Zip-Code

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Employer Phone Number

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Emergency Contact

First Name (*)

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Last Name (*)

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Relationship to Patient (*)

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Phone (*)

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Responsible Party (if minor patient)

First Name

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Last Name

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Relationship to Patient

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Date of Birth: Month

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Day

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Year

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View Privacy Policy

Patient Record Of Disclosures

In general, the HIPAA privacy rule gives individuals the right to request restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that the communication of PHI be made by alternative means, such as sending correspondence to the individual's office instead of the individual's home.

I wish to be contacted in the following manner:
(Please Check All That Apply)

Home Phone Number

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Ok to leave message with detailed information
Leave message with call back number only Invalid Input

Cell Phone Number

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Ok to text message (SMS) for appointment reminders and messages with staff (*)

Yes No

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Ok to leave message with detailed information
Leave message with call-back number only Invalid Input

Work Phone Number

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Ok to leave message with detailed information
Leave message with call-back number only Invalid Input

Written Communication

Ok to mail to my home address
Ok to mail to my work/office address Invalid Input

Patient Consent Form

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly
Obtain payment from third-party payers
Conduct normal healthcare operations such as quality assessments and physician certifications

I Agree (*)

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I have been informed of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices.

I Agree (*)

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I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also undestand you are not required to agree to my of request restrictions, but if you do agree, then you are bound to abide by such restrictions.

I Agree (*)

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I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

I Agree (*)

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All office visit charges and co-pays are due at the time services are rendered. It is the patient who is responsible for any and all financial aspects of services rendered. There will be a charge for returned checks, missed appointments without 24 hours notice and completion of any forms. I agree to pay for all deductibles, co-pays, non-covered services and any portion of covered services not paid in full by my insurance plan and understand that such payments are due at the time of service or immediately upon presentation of the bill. I hereby name Superior Foot and Ankle Care Center (SFACC) as my assignee. I instruct my health care benefits plan administrator, i.e. PLAN to pay SFACC directly for all professional and medical services provided by SFACC through the means of electronic funds transfer(s) (EFT) or by check(s) made payable to and mailed to SFACC. I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS CLAIMS.

I Agree (*)

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The above information is correct to the best of my knowledge. I understand that throughout my treatment, I am responsible for notifying the physician and/or medical staff of any and all updates to the information listed above. I also give permission for photographs of my feet to be taken that are to be kept as part of my medical record only. They will not be published as part of medical research or disbursed in any way without my permission.

I Agree (*)

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I acknowledge that I was provided a copy of the Notice of Privacy Practices for Superior Foot and Ankle Care Center and I have read (or had the opportunity to read if I so choose) and understood the Notice.

Payment Policy

Insurance: We participate in most insurance plans, including Medicare. If you are not insured by a plan we participate with, payment in full is expected at each visit. If you are insured by a plan we participate with but do not have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.

I Agree (*)

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Co-payments and deductibles: All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. If you have not met your deductible, we will collect a deposit to apply towards your deductible and co-insurance. Any remaining balance after submission to your insurance company is your responsibility.

I Agree (*)

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Non-covered services: Please be aware that some - and perhaps all - of the services you receive may not be covered or not considered reasonable or medically necessary by Medicare or other insurers. You must pay for these services in full at the time of visit.

I Agree (*)

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Proof of insurance: All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your driver's license and current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim.

I Agree (*)

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Claims submission: We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company.

I Agree (*)

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Coverage changes: If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits.

I Agree (*)

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Nonpayment: Invoices are sent out every 30 days. Your prompt payment will assist us in keeping the cost of healthcare down. If your account is over 60 days past due, you will receive a letter requesting immediate payment. Partial payments will not be accepted unless otherwise approved by Dr. Foley or Dr. Ornelas. Please be aware that if a balance remains unpaid, we may refer your account to small claims court and you and your immediate family members may be discharged from this practice. If this is to occur, you will be notified by regular and certified mail that you have 30 days to find alternative podiatric care. During that 30-day period, our physician will only be able to treat you on an emergency basis.

I Agree (*)

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Missed appointments: It is our policy to charge $35.00 for missed appointments not canceled within 1 day of scheduled appointment. These charges will be your responsibility and billed directly to you. Please help us to serve our patients better by keeping your regularly scheduled appointment.

I Agree (*)

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Forms and Documents: It is our policy to charge $25.00 for completion of all forms, such as disability applications, FMLA, etc.

I Agree (*)

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Surgery Cancellation: Failure to provide 5 business days notice of cancellation prior to scheduled surgery date will incur a $500 fee.

I Agree (*)

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Fees: Our fees are representative of the usual and customary charges for our area.

I Agree (*)

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The open payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at http://openpaymentsdata.cms.gov.

I Agree (*)

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I have read and understand the payment policy and agree to abide by its guidelines.

I Agree (*)

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PAYMENT RESPONSIBILITIES

We are pleased to welcome you to our office. New Patients are always appreciated. Our practice has grown as a result of its excellent relationship with our referring doctors and patients. As our patient, please feel free, at any time, to express any concerns or to ask any questions that you may have for the doctor or our staff. In order to assist you in making payment(s) for your podiatric treatment, the following options are listed. Please read them carefully and feel free to discuss them with us.

If you DO NOT have insurance: Payment is due, in full, at the time treatment is provided.

*For your convenience, we accept all major credit/debit cards and cash. We accept personal checks for payments under $50.00.

If you have Insurance: The percentage of coverage by your insurance company may be based on your insurance company’s own reduced fee schedule for medical services and may be less than actual charges resulting in lower coverage for you. Superior Foot and Ankle Care Center has no control over this situation. Lower payment is a direct result of the plan selected by you or your employer. Please be advised that we cannot waive co-payment. We are required by law to collect co-payment.

Commercial Insurance: We will submit your claim to your insurance carrier for you. You are responsible for any deductible or co-payment not covered by your insurance. Once our office has received payment from the insurance company, you will be billed, with 30 day terms, for any amount still owed. You may choose to keep a credit card on file for those balances left to you by your insurance company.

Medicare: This office accepts Medicare assignment. Medicare patients are fully responsible, however, for the initial yearly deductible and the 20% co-insurance. Federal law requires that physicians collect this amount. If you have a secondary insurance to cover the 20%, we will submit the balance to that insurance for payment and you will only be responsible for the yearly deductible.

Please sign with your initials (*)

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Please ensure you have completed all mandatory fields on this form (indicated with an (*) asterisk next to the field) and please wait until our thank you page loads to ensure the form was successfully submitted otherwise your data will be lost.

Please bring your insurance card and ID to your appointment.

Intake Form

Patient Information

Review of Systems

Social History

Family History

Insurance Information

Emergency Contact

Responsible Party (if minor patient)

Patient Record Of Disclosures

Patient Consent Form

Consent for Treatment and Acknowledgement of Policies

Payment Policy

PAYMENT RESPONSIBILITIES

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