PATIENT FORMS

PLEASE FILL OUT BOTH SECTIONS. THERE WILL BE 2 SUBMISSIONS TO OUR SECURE EMAIL ADDRESS.

AUTHORIZATION FORM    

AUTHORIZATION FORM - PODIATRY CARE OF MAINE

AUTHORIZATION FORM - PODIATRY CARE OF MAINE

PATIENT NAME - PLEASE PRINT

DATE OF BIRTH

CONSENT OF TREATMENT I authorize Podiatry Care of Maine, Robert B Taylor, DPM its health care practitioners, staff and other individuals involved in my care to examine me and perform any tests, procedures and/or treatments that may be helpful. I understand that the health care practitioner responsible for this care will explain any proposed procedures or treatments, including their usual and most common risks and hazards. i also understand that I have the right to refuse any proposed procedure or treatment.

SIGNATURE OF PATIENT, PARENT OR LEGAL GUARDIAN

DATE OF SIGNATURE

AUTHORIZATION FOR BILLING AND PAYMENT I understand that I am responsible for paying all costs associated with my care and treatment. If I have health insurance, I understand that I am financially responsible in the event that some or all payment is denied by my insurance carrier or other third party payer. I am also responsible for charges not covered by my insurance, such as deductibles, copays or full payment for non covered services. I authorize my health insurance carrier(s) or other third parties that are responsible for paying for my care to make payment directly to Podiatry Care of Maine. I authorize information to be sent to my insurance company. Medicare Patients: I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Finance Administration or its intermediaries or Carriers any information needed for this or a related claim. I permit a copy of this authorization to be use in place of the original and request payment of medical insurance benefits either to myself or to the party who accepts assignment. Regulations pertaining to assignment of benefits apply.

SIGNATURE OF PATIENT, PARENT OR LEGAL GUARDIAN

DATE OF SIGNATURE

AUTHORIZATION TO DISCLOSE HEALTH CARE INFORMATION Podiatry Care of Maine regards the safeguarding of your confidential health care information as an important duty. The elements of this authorization to disclose are required by state law for your protection and to ensure your informed authorization to the disclosure of health care information necessary to support your relationship with your physician. I, "PATIENT, PARENT AND/OR GUARDIAN", authorize Podiatry Care of Maine to disclose my health care information to health care practitioners and facilities that are involved in providing medical services to me. I also authorize disclosure of my health information to my family and close friends who are providing me with emotional support as I receive health care services. I understand that Podiatry Care of Maine will disclose such health care information which is necessary in the judgment of my physician for the legitimate needs of the recipient or for my general well being. Also, I authorize Podiatry Care of Maine to disclose my health information to my health insurance carrier, utilization review organization or benefit manager or any other third party who may be responsible for payment for services rendered to me. My health information, which is the subject of this authorization to disclose, includes demographic information; information about my physical or mental health or condition; information about the medical services provided to me, including payment information. Depending upon the services I request from my physician, this information may include information about treatment for sexually transmitted disease, mental health or substance abuse. I understand that I have a right to restrict Podiatry Care of Maine use and disclosure of my health care information and that they are not obligated to agree to the requested restriction. If they do agree, Podiatry Care of Maine will honor the restriction. I may revoke this authorization at any time by providing a written, signed, and dated request to the attention of the medical records supervisor at Podiatry Care of Maine offices. The revocation will apply except to the extent where information has been released prior to receiving the written notice. However, I understand that any restriction on the use and disclosure of protected health information or revocation of this authorization may result in improper diagnosis or treatment, a denial of coverage or a claim for health benefits or other insurance, or other adverse consequences. This authorization to disclose will remain in effect for all subsequent exchanges of health care information for the limited purposes outlined above for 12 months from this authorization date, unless I revoke it in the manner described above. I understand that if I have any questions about this authorization or if I wish to have a copy of this form, I may ask the office staff.

SIGNATURE OF PATIENT, PARENT OR LEGAL GUARDIAN

DATE OF SIGNATURE

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NEW PATIENT INFORMATION FORM  

New Patient Information

New Patient Information

Single Line Text

Single Line Text

TODAY'S DATE

PATIENT NAME

ADDRESS

CITY/ STATE AND ZIP CODE

HOME PHONE

WORK PHONE

CELL PHONE

Email Address

DATE OF BIRTH

SOCIAL SECURITY NUMBER

Checkboxes

MALE

FEMALE

OCCUPATION

EMPLOYER

PRIMARY PHYSICIAN

MARITAL STATUS

SINGLE

MARRIED

DIVORCED

WIDOWED

SPOUSE/ GUARDIAN

IF NOT REFERRED, HOW DID YOU HEAR OF OUR OFFICE?

PERSON TO NOTIFY IN EMERGENCY

EMERGENCY CONTACT'S PHONE NUMBER

Single Line Text

INSURANCE COMPANY

MEMBER ID OR INSURED ID#

SECONDARY INSURANCE NAME:

SECONDARY INSURANCE MEMBER OR ID#

NAME OF PERSON INSURANCE ISSUED UNDER

Paragraph Text SIGNATURE ON FILE AUTHORIZATION: I hereby authorize Podiatry Care of Maine to furnish information to insurance carrier concerning this illness/accident, and I hereby irrevocably assign to the doctor all payments for medical services rendered. I understand that I am financially responsible for all charges whether or not covered by insurance. __________________________________________________________ Signature of Responsible Person

Paragraph Text STATE IN YOUR OWN WORDS YOUR MEDICAL REASON FOR COMING TO OUR OFFICE:

Paragraph Text WHAT PROFESSIONAL OR SELF TREATMENT HAS BEEN ATTEMPTED FOR THE ABOVE CONDITION:

Single Line Text

PAST MEDICAL HISTORY: PLEASE CHECK ALL THAT APPLY

HIGH BLOOD PRESSURE

HEART DISEASE

KIDNEY DISEASE

HISTORY OF STROKE OR HEART ATTACK

LIVER DISEASE

DIABETES

ARTHRITIS

ASTHMA OR EMPHYSEMA

CANCER

STOMACH/INTESTINAL PROBLEMS

OTHER

Paragraph Text SURGERIES: PLEASE LIST SURGERY AND DATE PERFORMED _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________

PLEASE LIST ALL MEDICATIONS: LIST MEDICATION NAME, DOSAGE AND FREQUENCY

ALLERGIES

ALLERGIES TO MEDICATIONS

OTHER

IF YES TO ALLERGIES, PLEASE LIST BELOW

SUBSTANCE USE

DO YOU USE TOBACCO?

DO YOU USE ALCOHOL?

DO YOU RECREATIONAL DRUGS?

IF YES TO ANY OF THE ABOVE, PLEASE DESCRIBE SUBSTANCE, FREQUENCY OF USE, AND NUMBER OF USE PER DAY

FAMILY MEDICAL HISTORY PLEASE CHECK ALL THAT APPLY

ANY HISTORY OF DIABETES MELLITUS?

ANY HISTORY OF FOOT DEFORMITIES?

ANY HISTORY OF HEART DISEASE?

OTHER

FAMILY MEDICAL HISTORY - IF POSITIVE FOR ANY OF THE ABOVE, PLEASE EXPLAIN RELATIONSHIP AND CONDITION.

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