(MD- - Indian River Podiatry · Nicholas W" Indian River podiatry Futledge, D.P.M. MichaeiA.Mazziotta D.p.M. No Show Policy we are having an inffeasing issue with patients not showing

Indian River PodiatryNicholas W. Rutledge, D.P.M. Michael A. Mazziotta, D.P.M.

Name:(Last)

.ddd ress : (Street, City, Zip)

(First) (MD-

Date of Birth:

Work Phone#

Phone#

Social Security #

MartialStatus:MSDW Spouse l{ame:

Employer:

Prinnary Physician:

Pharmacy Name:

Who referred you to this office?

I)o you have a summer address? Yes or hloaddress and phone number:

Location:

If yes, please provide

May we leave a message? Y f N E

Alternate #

Email:

Emergency Contact (Other than spouse):Phone #I hereby authorize Dr. Nieholas W. Rutledge and/or Dr. Michasl [.TvIer.r.iotta tofurnish all necessary information to insurance carriers concerning my presentillness or accident.I also authorize payment for services rendered to be madedirectly to Dr. Rutledge and/or Dr.Mamiotta from my insurance carrier. I agree toaccept my responsibility for payment to the physician, even if my insurance carrierfails to pay, or a service is determined to be ttnot reasonable and necessary" by theMedicare/Insurance carrier. A photographic copy of this authorization shall bevalid as the original.

Signed: Date:

Nicholas W"Indian River podiatry

Futledge, D.P.M. MichaeiA.Mazziotta D.p.M.

No Show Policy

we are having an inffeasing issue with patients not showing up for their scheduledappointments' As a courtesy to al1 of our patients, *" *. inrtitoting a ,,No-Sh;;,policy.You will be charged a $25.00 'T'[o-showi fee, which i, ,oi covered by insurance should youviolate this policy' The purpose of this policyis to mairriuin better control of the schedule. whenthe office runs on time, everyone benedtr. w" thrrd;; advance for your cooperation.

1. You are counted as a No Show if:' You do not caII as or show up at aii" You do not cancel by 4 pm the business day befone your appointnnent

2' Youmay call our number o7z-s6g-0!sl) Jo cancel your appointment; you may leave amessage if it is after hours. You should do tiris r"fore i p.L. tnr business day before yowappointonent.

3' If you are counted as a.No show, you will receive a letter and billing statement in the mailreminding you of our policy and noting your No Show status.

1: B"i"g fhree (3) No shows within a six-month period, beginning from the date of the firstNo Strow will prevent yon from being able to schedule'further appointments and couldresult in discharge from the practice.

5' You will still have the. option of being seen on a,.stand-by,, (space avaitabie)basis.by one of our physicians, not necelssarily your ..grl* provider. you may have to waitawhile to be seen, if you are seen atillthatdly. e'--- 'r

Note: special consideration may be arranged with the office manager for,.emergencv,, casesonly' If you believe we have mad.e * "ooi

in r.rr"Jrii"g or vo, believe you deserve specialconsideration, please speak with the offrce maflager.

SignatureDate

INDIAN RI\rER PODIATRY, P.A"Nieholas W" Rmttedge, D.p.M. Michaet A.Mazziotta, D.p.M.

Patient Consent to the Use and Disclosure of Health fnformationX'or Treatment, Payment or Healthcare Operations

I understand that as part of my healthcare, Drs. Rutledge and Mazdottaoriginate andmaintainpapff and/or electronic records describing *in"atn histot,,r;;;r, examination,test results, diagnoses, treatrnent, and any plans or future care or treatnent. I understand that thisinformation serves as:

r d basis for planning my care and treatnent.o A means of communication among the many heaith professionals who contribute to mycare.

' A source of information for applylng my diagnosis and surgical information to my bill.. A means by which athird-parfy payor "* u"rig, that services billed were actuallyprovid.ed.

o d tool for routine healthcare operations such as assessing quality and reviewing ttrecompetence of healthcare professionals,

I understand that I have the following rights and privileges:' The right to review the notice prior to signing this consent.' The right to request reskictions as to how -y n.Atf, information may be used

or disclosed to carcy out treatment, paymen! or hea-lthcare operation-s.

I nnderstand that Drs. Rufledgs alf,}llaz.ziotta are not required to agree to the restrictionsrequested. I understand that I may revoke this consent in writing, eicept to the extent that theorgarttzatton has already taken action in reliance thereon. I also undersiand that by refusing tosign this consent or revoking this consent, this organi zationmay refuse to treat me as permittedby Section 164.506 of the Code of Federal regulations.

Drs' Rutledge and Mazziotta reserye the right to change their privacy practices as described intheir Notice of Privacy Practices. If they change theirlrivacy practices, they will issue a revisedNotice of Privacy Practice, which wiil contain-the changer. fror" changes Luy upprv to any ofmy protected health information that they maintain.

I understand that as part of this organization's heatrnent, payment, or healthcare operations, itmay become necessary to disclose my protected health inLformation to another entity; and Iconsent to such disclosure for these permitted uses, including disclosures via fax.

I fully understand and accept.

Print Name

Patient Signature

DOB: Date:

Name:

Name:

Name:

Indian River PodiatryNicholas W. Rutledge, D.P.M. Michael A.Mazziotta, D.p.M.

Patient Consent to Disclosure of Health fnformationFor personal use

I wish to give the following person(s) access to the use or disclosure of my health information,appointments and/or account information.

Name: Reiationship:

Relationship:

Relationship:

Relationship:

Please print

Please print

PIease plint

Please print

DOB: Date:Print Name

Patient Signature

ffiEl

DO NOT COPY ELANX FORMS. OBIGINAL F0RMsWlLLHAvEAMATcHlI{0Ut{lQuEFE0sEHlALI{U$EEfi0\{EBlt{lff8{F,*lilJs{loIH.]ry:yI9a}r

G'irlffi DOCUFORMS* POD-2010

Confidential Office Medicat Record\fn 0nly Changes To The Previous

-X| - History lnformation Are Noted

\J-rr Perrerur loerurrrrcATroN aruo CoruTAcr lruroRnaanroruFirst Name: Ml: Last Name: Your type of Job Activity / Occupation: L-l I preler to be addressed as:

E@@@En I prefer to be addressed by: C First Namr

O Nick N"me,

L_]

zf,Dl-

odI

,/

Last 4 digits ofSocal Sec. #:

Sex

M/FAge Birth Date: Shoe

Size:Weight: Height:

Phone Numbers For Contacting You:

Dav: ( )

ln Case of Emergency, Please Call: Please Provide Your Preferred Pharmacy:

Evening: (- )

Cell/Pager: (

-

)

Day: (-)Evening: (- )

Street / City:

Day: (- )

-.?l EDrcAL HrsroRv ROS/PFSH

Have you had/been treated for: E Warts I Athlete's FootI Corns/Calluses E Fungal Nails E lngrown nailsE Leo or Foot Ulcers E rueuioma I root NumbnessE arJken foot bone(s) E Broken Ankle I Ankle sprainE Hammer/Mallet toes E Bunions I Flat feetE Crarps in legs/feet E Arch pain E High arch feetE lo*"iback p-ain E Knee pain -l

Heel pain

i---r Gait (Walking) problems r,'; ln-toeing ii Toe walkingE cnitotrooo foot problems E Rastr E worue of theseDid you prcviously or do you now wear:

Shoe inserts? E N Stitt using them? E E Do or did they help? E E0rthotics? E N Still using them? E E Do or did they help? E NThe orthotics were obtained from: Q Another Podiatrist Q An 0rthopedist

Q APhysicalTherapist Q AChiropractor Q 0ther:

Are your first steps out oI bed painful? E N ...then subsides? E ElDo you get leg cramps ..,during the Datr E N ...at Night? E EPercent of waking hours spent on your feet? E0"/-lEo%I reo%-lEo%-lli00%l

List the sports/type of dance your are active in:

List relationship to you of family members who have had:

DiabetesArthritis

Foot ProblemsHeart AttackHigh Blood PressureBidh DefectsCancer

# of childbirths _ Are you currently pregnant?

Are you slow to heal atter cuts?Any abnormal bruising, bleeding or scarring?Do you smoke now? E No n Yes Packs/dayDid you ever smoke? E No I Yes Packs/day

lf you quit, when did you do so?Alcoholic beverages? (circteone) None Rarely Moderately Daily Quit

Recreational Drugs? (circteone) None Rarely Moderately Daily Quit

Please mark if you take vitamins or supplements that contain a garlic,

O Gingko bitoba, O echinacea, C glnseng or C St. John's Vlorl

Are you currently taking any medications? List belowl ' Yes - No

Are vou takinq lnsulin? lf yes, list below. - Yes - No

E Yes No

Notr

tri y",_ Years

Years

\

trcttr

Ei

otI

aIoT

Imz

!Itz-{

Ia{0I

a011

When noting frequency: A = As ne€ded, x./ = times per D = clay, U/ = week"

List: Medications Dose? How Often? For Treatment of?

Does foot pain limit your desired activities? [ Yes IDo you have any difficulty in walking? [ Ves IAny pain in calves or buttocks when walking? tr Yes Ils the pain relieved by stopping & standing still? [ Ves IDo you have or have you ever been treated for:E Strote E HeartAttack f High Blood PressureE pf,teoitis E Vascular Disease I n fteart Condition

No

NoNoNo

E Anemia E Poor Circulation I Eyes:Glaucoma/Manicular Deg.

E Dirbetes E Kidnev Disease I rbtoionr,ict s"utE cout E osteotorosis n Alzheimer'sE Sciatica E Lvme s Disease E Rheumatic FeverE Rrtnritis I Heaoacnes --] Hearing/Ear DisorderE rpitepsy E Nerve Disorder E Psychiatric DisorderL-l Asthma L--l Luno Disease L l TuberculosisE Heoatitis E lir"i Disease E trrvroid ProblemE oait Urine E Chronic Light Stool E Unlxplained Weight Loss

E cancer E stomach ulcer E NoA/E of thesef l n+n^"r.t.

E, -VEEE, -xlEE@, _xrEE

E, _x/EEEl x/lolM

Are you taking your medications as prescribede ---E V". tr NoAllergtes; ls tnere a nrslory oI sKln reacllon or olner ourwaro reacrlonor sic-kness lollowing an in]ection, oral or topical administration of:(Check the answer box that applies) (No ies) f /fyes, whathappens'/ LLatex, Adhesive lape (circle)......... IPenicillin .... .. . .. -Other antibiotics (list below).......... IEmpirin, \ylenol (if yes, circle)....... l)Aspirin, Advil, Aleve, or l,lotrin lcicl4 ECelebrex trOther pain remedies (list below)... llMorphine........ ICodeine................... . trDemerol trOther narcotics (list below)............ l)Novocaine IOther anesthetics (list below).. trSulfa drugs nShrimp, lodine, or Merthiolate.... EAny other drugs or medications. IOthers:

=-l_llIllIIlllII

Do you have vascular grafts? (tf yes, exptain betow) E yes I NoDo you have joint implants? (tf yes, exptain betow) E yes I NoDo you have replacement heart valves? E yes E ttoAre you now under active chemotherapy? I yes E noHave you had any other serious illness? (List betow) I yes I ttoHave you had any surgery? (tf yes, exptain betow) I yes I NoHave you ever been hospitalized or been under [] yes I Nomedical care over 24 hrs? (lf yes, explain below)I Had Surgery for: on date of: w/ complications of: Anything else that you want to tell the doctor? L lves I trto

I I I nesses / Expl an ati o n s :

Plense Corurrxue oN THE OrneR Stpe ro PRovloe Aootrlorel Derntls, Patient I1CC# (s) \ );:

10 , j l.:,r",lii,: i.,-e ;a ;."r!,"i,fii*u{:ri: -":.. "r}i. , , :.4;i f }{;"1 :,-ir:;::; i-ftSfi.{";1;,}1IJ