Manhattan Podiatry Associates P.C. NYC Foot & Ankle OBS,P.C. REGrsrfSJl?i FoRM Today's Date Patient'sLast Name tr Mr. tr Miss trMrs D Ms Marital Status (Gircle One) Single / Mar / Div / Sep / Wid Birth Date Sex trM trF Address Social Security # Home Phone No. City State ZIP Code E-Mail Address Occupation Employer Business Phone No. () Cell Phone No Referred to Office by D Advertiseme O Doctor 0 lnsurance tr Internet tr Other OPatient/Friend NAME OF PRIMARY INSURANCE Policvholder's name. Policyholder's S.S.# Birth Date Group # Policy # Co-Payment Patient's Relationship to Policvholder tr Self O Spouse A Child O Other NAME OF SECONDARY INSURANGE Patient's Relationship to Policyholder O Spouse Medical Doctor's Name/Address lurrent foot complainUsymptoms Name of Local Friend or Relative (notliving at same address) Work Phone No () The above informationis true to the best of my knowledge. I authorize my insurancebenefits be paid directly to the physician.I understand that I am financially responsible for any balance. I also authorize Manhattan Podiatry or insurancecompany to release any informationrequiredto process my claims. I acknowledge that I was provided and read (or had the opportunity to read)and understood The Notice of Privacy Practice am aware that the following information is available for viewing upon request; o Information regarding the providers of care in this organization . A copy of the Patient's Bill of Rights and Responsibilities . Information regarding the grievance process . Ownership of Practice . DNR Policy . JCAHO lnformation PATIENT/GUARDIAN SIGNATURE DATE