BEDFORD PODIATRY & FOOT SURGERY, PC Dr. …Surgery, PC all claim benefits, if any. I acknowledge and understand that I am financially and fully responsible for all charges incurred

BEDFORD PODIATRY & FOOT SURGERY, PCDr. Robert Feldman876 E. Main StreetBedford, VA 24523

Today's Date: ___________________

Patient's First Name: ________________________M.I: ______ Last Name: ___________________________

Date of Birth: __________ Gender: M/F Soc. Sec.#___________________Ethnicity:___________________

Address: _________________________________________City: _____________________ State: _______

Zip: _________________ Home Phone: ____________________ Work Phone: ______________________

Cell Phone: __________________ Email Address: ______________________________________________

Employment Status: Employed/Unemployed/Retired Employer: _________________________________

Occupation: ____________________ Martial Status: _________ Spouse:____________________________

Next of kin: ____________________________________ Next of kin phone:___________________________

Who referred you to our office? _______________________________________________________________

Emergency Contact Name: _______________________________ Relation to Patient: ______________

Emergency Contact Home Phone: ________________ Emergency Contact Work Phone: _______________

Responsible Party for minors: _____________________________________ DOB: __________________

Responsible Party Phone Number: ____________________ Cell Number: ________________

Responsible Party Address: ___________________________________________________________________

How did you hear about us: ___________________________________________________________________

MEDICAL HISTORY

Reason for today's visit? _____________________________________________________________________

Date of last exam? _______________________ By whom? ________________________________

What is your main concern about your feet/legs? __________________________________________________

Which foot is bothering you? Right/Left/Both How long have you had the current problem/condition?

____________________ What have you done to treat the problem yourself? ________________________

Height: ____________ Weight:__________ BP:________________

Primary Care Provider(PCP): ________________________Dr's Phone: ___________Date Seen:____________

Are you currently taking any medications? If so please list (including oral contraceptives, aspirin, OTC and/or herbal supplements) _____________________________________________________________________________________

Do you have allergies to any medications? Y/N If so please list: ____________________________________

Type Allergy-Medication/Name/Reaction Details: _________________________________________________

List all surgeries and/or hospitalizations you have had: _____________________________________________

Are you pregnant or nursing? Yes /No

Check any of the following medical conditions you have had:

Pneumonia Arthritis/Gout Nervous Disorder Stroke Epilepsy

High/Low Blood Pressure Diabetes Skin Disease Varicose Veins

Keloid (scar) Formation Anemia Cancer/Tumors Hay Fever/Asthma

Thrombophlebitis (blood clots) Frequent Colds/Sore Throat Bone Disease

Bleeding Tendencies HIV/AIDS Liver Disease Swollen Feet/Ankles

Tuberculosis Hepatitis COPD Fibromyalgia

Other: _________________________________________________________________________________

FAMILY MEDICAL HISTORY

Please note any family history for the following:

DISEASE/CONDITION - Please circle and note which family member had this condition

Cancer/Type Diabetes Heart Trouble High/Low BP Kidney Disease Lupus Thyroid Disease Other _______________________________________________________

Mothers Name/DOB ____________________________ Fathers Name/DOB__________________________

SOCIAL HISTORY

(This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.) Do you use tobacco products? Y/N If yes, type _______________ Amount _________ Date started_________

For Former Smokers: Date quit _____________________________

Do you use illegal drugs? Y/N If yes, type/amount/how long: _____________________ Do you consume alcohol? Y/N If yes, type/amount/how long: _____________________

Have you ever been exposed to or infected Gonorrhea /Hepatitis /HIV/Syphilis ( with please circle)

I, the patient/guardian/responsible party, have accurately and truthfully completed the information listed on this form. I agree that all fees incurred are my responsibility regardless of insurance coverage. I acknowledge that I have received a "Notice of Privacy Practices" regarding the use and disclosure of my health information (Form is available at front desk).

Your Name: _______________________________ Date: ___________________________________

We participate in numerous insurance plans and gladly handle the paperwork required to efficiently submit claims directlyto each different carrier. However, if you participate in an insurance plan that requires a referral from your primary care provider in order to be seen, you must provide us with such referral prior to your visit. Unfortunately we are unable to secure retroactive referrals. The insurance company will not pay for your treatment and office visits without a valid referral in place. Please be aware that verification of coverage is not a guarantee of payment. Decisions of payment is made at the receipt of claim made by your insurance company. Additionally, please note that many insurance plans no longer cover “Routine foot care” (cutting of corns, calluses and toenails). Non routine foot care will be billed directly to the patient.

I acknowledge that I have read and understand the above paragraph and its contents.

Patient Name: ____________________ Date: __________ Patient Signature:__________________________

***Self Pay Patients must pay in full at the time of the service. Insurance will be verified and accepted, however, the co-pay, deductible and/or any non-covered charges must be paid in full at the time of the visit. ***

RELEASE AND ASSIGNMENT

I, the undersigned, hereby authorize the release of all information necessary to secure the payment benefits submitted for service rendered by my physician/provider on behalf of myself and/or my dependents. I further expressly agree and acknowledge that my signature on this document authorizes my physician/provider to submit claims for benefits for any services rendered without obtaining my signature on each and every claim form, and that I will be bound by this signatureas though the undersigned had personally signed the particular claim.

I, the undersigned have coverage with the insurance company listed above and assign directly to Bedford Podiatry & FootSurgery, PC all claim benefits, if any. I acknowledge and understand that I am financially and fully responsible for all charges incurred from services rendered by my physician, whether or not paid by the insurance. If any portion of my account balance is not reimbursed by my insurance company for any reason, I agree to cooperate and arrange prompt payment in full to clear my bill. I understand that payment is due upon receipt of my monthly statement.This release and assignment is effective for the period of 2016-2019.

Signature of Patient/Legal Guardian________________________________ Date_____________________

Authorization does not apply to Medicare patients who are fee paying (as a courtesy we will file claims with medicare. Ifyou have Medicare, please sign below acknowledging the information is accurate to the best of your knowledge.

Signature or Medicare Patient ____________________________________ Date __________________