Please answer the following questions. Comfort Foot Care HIPPA COMPLIANCE FORM 1. What is your contact preference? Circle all that apply Home Phone Cell phone Mail Email SMS 2. May we leave lab, testing results, appointment reminders and surgical procedure dates on your home answering machine or cell phone voicemail? Circle your answer YES NO Patient Signature: Date: / / 3. Please list the names of people you do allow us to share your health information with if you are unavailable. Name: Relationship: Name: Relationship: 4. What is your primary language? The following questions are optional. Please check the answer that best fit you. 5. Race: American Indian or Alaskan Native Asian Black or African American Native Hawaiian or other Pacific White Prefer not to answer 6. Ethnicity: Hispanic or Latino Not Hispanic or Latino Prefer not to answer I certify that the information given above is true and correct. I understand that it is my responsibility to notify Comfort Foot Care, LLC of any changes to the above information. Patient or Guardian Signature: Date: / / Dr. Mario Dickens 6116 Shallowford Road, Suite 118, Chattanooga TN 37421 ph 423.710.1224 fax 423.710.1228 www.chattanoogafootdoctor.com
Comfort Foot Care Assignment of Benefits and Financial Agreement My signature at the bottom of this form authorizes payment for services rendered to my self or my dependent to be made directly to Comfort Foot Care. This authorization is valid until I notify Comfort Foot Care in writing that it is revoked. I understand that I am responsible for giving Comfort Foot Care the correct insurance information at the time services are rendered. Comfort Foot Care agrees to bill your primary insurance carrier. If you have more than one insurance we will bill your secondary insurance one time as a courtesy. If payment is not received from your secondary within 45 days the balance becomes your responsibility. All insurance information must be provided to our office, at the time of service. I understand that I am responsible for obtaining the proper referral and may be held responsible for charges not covered by my Insurance due to my failure to obtain that required referral. I agree to pay for non-covered services under my insurance plan (services for which I have policy exclusions). I understand that Comfort Foot Care is not responsible for knowing if the group/physician is a participating provider with my insurance carrier. We at Comfort Foot Care expect that all accounts should be paid by the receipt of the first two statements. If your account has not been settled either by payment in full or by contacting our billing department to set up a payment plan we will forward your account over to collections. Please Note: Comfort Foot Care is a member of the Lazarus Financial Group Network. As such, any patient whose account is not cleared in a timely manner will be sent to Lazarus Financial Group. Any Fee(s) that Lazarus Financial Group charges this office for the collection of a delinquent patient account becomes the responsibility of the patient. I understand that there is a $35.00 fee for all returned checks. I understand that I am responsible for all balances not paid by my insurance carrier, including deductibles, co-pays, co-insurances, and out of network penalties. I further understand that if this balance is turned over to an outside collection agency that I shall be liable for all costs of collection, any attorney fees, and or court costs incurred by this office. Patient or Patient s Guardian or Legal Representative Date Name of Patient or Guardian or Legal Representative Relationship to patient
History & Medical Information 1. Primary Care Physician: Phone: Date of Last Visit: / / 2. What is your Height: Weight: What is your occupation? 3. Explain your foot/ankle problem: 4. When did pain/discomfort begin? Date: / / Describe pain: Burning Numbness Sharp Other Describe how painful: If 0 = no pain and 10 = the worst pain you ever had 1 2 3 4 5 6 7 8 9 10 5. What makes pain/discomfort better? 6. What makes pain/discomfort worse? 7. Has condition been treated? YES NO When and how? 8. Past Medical History: Anemia Gout Kidney Disease Other Arthritis Bleeding Disorders Cancer Stroke Diabetes Epilepsy Heart Disease Hepatitis HIV/AIDS Poor Circulation Osteoarthritis High Cholesterol STD Asthma Arthritis Thyroid Disorder Prostate Disorders Mental Illness Stroke Other: If Diabetic, please list the name and phone number of the doctor treating you for Diabetes. 9. List all Medications/Herbs/Vitamins: NONE Which pharmacy do you use? Medicine Name Dosage Medicine Name Dosage 10. Allergies: NONE Sulfa Drugs Penicillin Aspirin Food Shellfish Cortisone Iodine Demerol Darvocet Latex Environmental Codeine Anesthesia Type of Reaction 11. Have you had Surgery Before? (Please list any and all surgeries and dates) YES or NO 12. Social History: Current everyday smoker Current Someday smoker Former Smoker Alcohol Use Caffeine Use Recreational Drug use Exercise Habits Are you pregnant? Are you nursing? 13. Family History: (Please list the relationship of members(s) who have had problems) Diabetes Heart Disease High Blood Pressure Mental Illness Stroke Kidney Disease Cancer Other Family History:
Review of Systems (Please Circle your selections) 1. Constitutional Systems: Fever Chills Sweats Weight Loss NONE 2. Head, Eyes, Ears, Nose and Throat: Do You. Wear: Contacts Dentures Eyeglasses NONE Have: Double Vision Cataracts Dizziness Ringing in Ears Difficulty Swallowing Neck Pain Sore Throat Nose Bleeds NONE 3. Cardiovascular: Chest Pain/Heart Attack Congestive Heart Failure Heart Murmur Palpitations Swelling in Legs/Ankles Leg Pain w/exercise Cardiovascular Surgery NONE 4. Hematological/Lymphatic (blood) History of: Bleeding abnormalities Anemia Lump in Groin or Armpit Lymphoma Swollen Glands NONE 5. Respiratory: Shortness of Breath Emphysema Cough Bronchitis Pneumonia Asthma Difficulty Breathing Wheezing TB Exposure/Treatment Previous Pulmonary Disease NONE 6. Gastrointestinal: Nausea Vomiting Diarrhea Constipation Stomach Ulcers Decrease in Appetite Blood in Stool Hepatitis Acid Reflux NONE 7. Endocrine: Often Thirsty Often Urinating Kidney Disease Pancreatitis Diabetes Mellitus Prostate problems Thyroid Disorder NONE 8. Musculoskeletal: Tendonitis Bursitis Broken Bones Arthralgia Joint Pain Feeling Weak Weakness of limbs NONE 9. Nervous Systems: History of. Migraines Seizures Strokes Nervous Disorders Ataxia (loss of balance) Aphasia (loss of Speech) Confusion Neuropathy (loss of sensation) Speech Difficulties Fainting NONE 10. Integumentary: Rash Skin ulcers Lesions Sensitivity to Sun Change in skin color Recurrent Infections Eczema Hair loss Keloid Growth on Skin Cracking of Skin NONE 11. Psychiatric: History of.. Nervousness Tension Depression NONE To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. Patient/Guardian Signature: Date: / /
Comfort Foot Care ACKNOWLEDGEMENT 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 understood the Notice. *** Patient Name (please print) Date Parent/Legal Guardian or Authorized Representative Signature Date *** Packets are available at the front window *** Dr. Mario Dickens 6116 Shallowford Road, Suite 118, Chattanooga TN 37421 ph 423.710.1224 fax 423.710.1228 www.chattanoogafootdoctor.com
Comfort Foot Care Patient Information (Please print) Name: Date of Birth: / / Age: Address: Street Apt# City State Zip SSN: / / Sex: (Please circle) MALE FEMALE Home Phone: ( ) - Work: ( ) - Cell: ( ) - Email Address: Employer: Why Email? Notifications that your patient records are accessible and ready to be downloaded for your use will be sent to this email address. Internet access is needed for this function. Emergency Contact Information Name: Relationship: Home Phone: ( ) - Work: ( ) - Cell: ( ) - Responsible Party/Primary Insurance Carrier (If not Self) Name: Date of Birth: / / Relationship: Address: Street Apt# City State Zip SSN: / / Sex: (Please circle) MALE FEMALE Home Phone: ( ) - Work: ( ) - Cell: ( ) - Employer: Employer Phone: ( ) - Dr. Mario Dickens 6116 Shallowford Road, Suite 118, Chattanooga TN 37421 ph 423.710.1224 fax 423.710.1228 www.chattanoogafootdoctor.com