mark r. williams, dpm, facfas christopher t. … · 2017-10-31 · primary care physician: ......

D A V I S O N • L A P E E RD A V I S O N • L A P E E RD A V I S O N • L A P E E R

Patient Name: ___________________________________________________________ Date: ________________ (First) (Middle) (Last)

Date of Birth: _______________ Sex: M F Marital Status: S M W D S.S.# ________________

Address: _____________________________________________________________________________________ (Street) (City) (State) (Zip + 4)

Phone: _____________________ Cell: _____________________ E-Mail: _________________________________Primary Care Physician: _________________________________ Date of Last Visit:_________________________Spouses Name: _____________________________ Date of Birth: _____________ Employer: _________________Emergency Contact:____________________________________ Phone: __________________________________

Required by Medicare Ethnicity: Not Hispanic or Latino Hispanic or LatinoRace: White Black Asian American Indian or Alaska Native Hawaiian or Pacific Islander

Primary Insurance: ____________________________________________ I.D. # ___________________________Policy Holders Name: ___________________________________________ Date of Birth: ____________________Policy Holders SS#:_______________________________ Relationship to Patient: __________________________ Secondary Insurance: _________________________________________ I.D. # ___________________________Policy Holders Name: ___________________________________________ Date of Birth: ____________________Policy Holders SS#:_______________________________ Relationship to Patient: __________________________Is this Worker’s Comp? Y N Auto Accident? Y N Other Acciddent? Y N

Complete this Section if Patient is a MinorResponsible Party: _______________________________ Relationship to Patient: ___________________________Date of Birth: ____________________________________ SS#: _________________________________________Address: _____________________________________________________________________________________

How did you learn about our office? Doctor Referral (name) __________________________________________Friend ________________________________________ Family _______________________________________ Hospital (ER) Website Phone book Sign Previous Patient

I attest that the information provided on this form is complete and accurate to the best of my knowledge. I hereby authorize Professional Foot & Ankle Centers, P.C. to furnish any medical information necessary to process insurance claims for my treatment acquired in the course of the examination or hospitalization. I au-thorize payment of medical and/or surgical benefits to Professional Foot & Ankle Centers, P.C. I understand that the provider’s charge may exceed the insurance allowed amount and payment. I will be responsible for any and all balances such as co-insurance, co-payments, and deductibles.

_________________________________________________________ _____________________________Signature of Patient/Legal Guardian Date

_________________________________________________________Print Name

PAT I E N T I N F O R M AT I O N F O R M

DAVISON: 605 South State Road • Davison, MI 48423 • (P) 810.653.9060 • (F) 810.658.2248LAPEER: 1390 North Main Street • Lapeer, MI 48446 • (P) 810.664.1250 • (F) 810.664.0315

ProfessionalFoot.com

Mark R. Williams, DPM, FACFASDiplomate, American Board of Foot & Ankle SurgeryFellow, American College of Foot & Ankle Surgeons

David T. Hehemann, DPM, FACFASDiplomate, American Board of Foot & Ankle SurgeryFellow, American College of Foot & Ankle Surgeons

Christopher T. Hehemann, DPM, FACFASDiplomate, American Board of Foot & Ankle SurgeryFellow, American College of Foot & Ankle Surgeons

Primary Care Physician: __________________________________________ Date of Last Visit: _____________ Do you have Diabetes? Y N If so, do you wear Diabetic shoes? Y N Doctor Managing Diabetes: _______________________________________ Date of Last Visit: _____________

Chief Complaint (Specific concern you would like addressed by your doctor today?) ________________________________

_______________________________________________________________________________________________

When did your condition first begin? #____ Days Ago #____ Weeks #____ Months #____ Years Ago

Was it related to an injury? ____No ____Yes What Type?________________________________________

Which activities make your condition worse? (Please check answers)

Standing up from a seated position Walking Running Uneven ground Certain Shoes Athletics Work

Exercise Lifting Walking Barefoot Other: _______________________________________________

Which of the following treatments have you tried? (Please circle answers)

Anti-inflammatory medications Physical Therapy Stretching Shoe Modifications Padding Inserts

Bracing Cortisone injections Surgery Aspirin Tylenol Pain Medications Soaks

Ice Heat Rest Topical medications Other: __________________________________________

Does anything make your condition better? ____No ____Yes If so, Explain: ____________________________

Mark the scale to indicate your average pain due to your foot and ankle condition.

. 0 1 2 3 4 5 6 7 8 9 10 . No Pain Worst Pain Imaginable

Has any other physician/person treated this condition? ____No ____Yes

If so, whom and when: ___________________________________________________________________________

Have you ever been to a podiatrist before? ____No ____Yes

If so, who: ____________________________________________________________________________________

INTERNAL OFFICE USE ONLY

Name: _________________________________________________________________ Date:________________

Birthdate: ________________ Age: _______________ Height: _________________ Weight: ________________

Occupation/Employer ___________________________________________________________________________

Pharmacy _____________________________________________ Pharmacy City __________________________

***** Don’t Forget to Complete the Other Side *****DAVISON: 605 South State Road • Davison, MI 48423 • (P) 810.653.9060 • (F) 810.658.2248LAPEER: 1390 North Main Street • Lapeer, MI 48446 • (P) 810.664.1250 • (F) 810.664.0315


M E D I C A L H I S T O R Y F O R M





Past Medical History (Please check all that apply)

Review of Systems (Please check all items that apply currently or recently)

1. Constitutional Symptoms Fever Chills Headache no symptoms 2. Eyes Blurred Vision Double Vision Eye Pain no symptoms 3. Ears, Nose, Throat, Mouth Hearing Loss Sore Throat Sinus Problem no symptoms 4. Cardiovascular Chest Pain/Pressure Calf Cramping Heart Palpitations no symptoms 5. Respiratory (Lungs) Shortness of Breath Wheezing Frequent Cough no symptoms 6. Gastrointestinal Nausea/Vomiting Heartburn Abdominal Pain no symptoms 7. Genitourinary Painful Urination Urinary Frequency Urine Retention no symptoms 8. Musculoskeletal Joint Pain Joint Swelling Stiffness no symptoms 9. Integumentary (Skin) Foot Ulceration Discoloration Rash no symptoms10. Neurological Numbness/Tingling Tremors Paralysis no symptoms11. Psychiatric Addiction to Alcohol Depression Anxiety no symptoms12. Endocrine Fatigue Excessive Thirst Heat Intolerance no symptoms13. Hematologic/Lymphatic Foot or Ankle Swelling Swollen Glands Bleeding Problems no symptoms14. Allergic/Immunologic Recent Asthma Attack Seasonal Allergies Drug Allergies no symptoms

Allergies (Please check all that apply)

o No Known Drug Allergieso Adhesive Tapeo Aspirino Codeineo Demerolo Iodineo IV Dyeo Latexo Local Anestheticso Penicillino Sulfao Other ____________________

Past Surgical History (Please check all that apply)

o Amputationo Angioplasty (heart stent)o Appendectomy (removal of appendix)o Back surgeryo Bariatric surgeryo Carpal tunnel surgeryo Cholecystectomy (gall bladder)o C-sectiono Eye surgeryo Foot surgery (what?) ______________o Heart bypass

o Acid Reflux/GERDo Alzheimer’s/Dementiao Anemiao Arthritiso Asthmao Cancer/Type _____________o Chronic Back Paino Cirrhosiso Congestive Heart Failureo Depressiono Diabeteso DVT (blood clot in leg)o Emphysema/COPDo Fibromyalgiao Gout

o Heart Attacko Heart Beat Irregularo Heart Murmuro Heart Diseaseo Heart Pacemaker/AICDo Hepatitiso High Blood Pressureo High Cholesterolo Hypothyroid (low)o HIV/AIDSo Kidney Dialysiso Kidney Diseaseo Kidney Transplanto Mental Illnesso Multiple Sclerosis (M.S.)

o Osteoporosiso Parkinson’so Peripheral Arterial Disease (PAD of legs)o Peripheral Neuropathyo Phlebitiso Psoriasiso Pulmonary Embolism (blood clot in lung)o Raynaud’s Diseaseo Rheumatoid Arthritiso Seizureso Sickle Cell Anemia/Traito Sleep Apneao Stomach Ulcerso Strokeo Other ___________________________

o Hernia repairo Hip replacemento Hysterectomyo Knee replacemento Knee scopeo Mastectomyo Thyroid removalo Tonsillectomyo Vascular surgeryo Other _______________________o Hospitalizations _______________

Family History (Please check all that apply) o Arthritis o Cancer o Diabetes o Heart Disease o Other___________

Social HistoryDo you smoke? Yes No How much? ____________ How long? ____________ Quit when? ______________Do you drink alcohol? Yes No How much? __________________Do you use illicit drugs? (marijuana, cocaine, etc.) Yes No Explain ___________________________________

Signature of Patient/Legal Guardian_____________________________________________ Date__________________

Physician Signature (Form completely reviewed)______________________________________ Date __________________

Medications1. ______________________ 4. ______________________ 7. ______________________ 10. _______________________2. ______________________ 5. ______________________ 8. ______________________ 11. _______________________3. ______________________ 6. ______________________ 9. ______________________ 12. _______________________

Welcome and thank you for choosing Professional Foot & Ankle Centers, P.C. We are committed to providing you with the highest

quality medical care in an efficient, timely, and effective manner. Please review our financial policy below. If you have any

questions, please feel free to discuss them with our staff.

1. Insurance Coverage: Your insurance policy is a contract between you and the insurance company. As a courtesy, we will

file your insurance claim for you. This allows the insurance company to pay the doctor’s office directly. We are a specialist

office and it is always wise to verify your insurance benefits, co-pays, and deductibles prior to your visit or procedure. We

will make a copy of your insurance card and driver’s license during your initial visit. Existing patients are to inform us of any

changes in insurance coverage or demographics that may have occurred since your previous visit.

2. Co-Payments: Most insurance plans have a Co-Payment (co-pay). This is an amount you must pay upon each visit to a

doctor. Our policy is to collect your co-payment at the time of service. If you are not prepared to pay the co-payment, the

visit will be rescheduled. We accept Cash, Check, Debit Card, Visa, MasterCard and Discover.

3. Deductibles: In addition to the co-payment, most plans also have an annual deductible. If you have not met your

deductible you will be billed for the anticipated approved insurance amount. Payment is expected at the time of service. In

the event there is a balance due from you after your insurance carrier has paid its portion we will bill you. We would

appreciate prompt payment of your bill after the first statement. If you do not understand the reason you owe a balance,

please do not hesitate to contact our office, and the billing staff will explain the balance to you, and answer any questions

you might have. If your account becomes past due, we will refer the overdue balance to an outside collection agency.

4. Referrals: If you are enrolled in an HMO, which requires a referral from your Primary Care Physician (PCP), it is your

responsibility to make sure our office has a copy. You are responsible to keep track of the visits allowed and the expiration

date of your referral. If a referral is not in place, your appointment may be rescheduled or any services received without a

referral or proper authorization will be your financial responsibility.

5. Non-Covered Services: Your insurance plan may not cover all services and/or supplies provided to you during your

treatment. In the event your health plan determines a service or item to be “non-covered”, you will be responsible for total

charges at time of visit or upon receipt of a statement from our office.

6. Forms: There will be a prepaid fee of $20 per form for completing individual medical forms, disability forms, work

restriction forms, FMLA forms, employer forms, AFLAC forms, school forms, etc. Payment is due at the time that you

request the forms to be completed. Please allow 7 business days for the completion of these forms.

7. Returned Checks: A $35 fee will be charged for any checks returned by the bank.

8. Custom Orthotics: An attempt can be made by our office staff to determine insurance coverage for custom orthotics. If at

the time of your visit insurance coverage has not been determined you will be responsible for $175 which will be applied to

the cost of your orthotics. The balance of the orthotics will be due at the time the orthotics are dispensed. If you’re

insurance company pays all or a portion of the orthotic cost and this results in an overpayment on your account, a refund

will be made to you. Our cash pay price for 1 pair of custom orthotics is $350. When you agree to have a custom orthotics

made you are agreeing that you will be financially responsible for the cost of the device regardless of insurance coverage. If

your orthotics are not picked up in a reasonable amount of time, we will mail them to you and charge your account

accordingly.

Please sign below if you have read, understand and agree to the above eight financial policies of Professional Foot & Ankle

Centers, P.C. I understand that I am financially responsible for any deductible, co-insurance, co-pay, non-covered service or

unmet balance and any other charges my insurance may not cover.

Signature of Patient or Responsible Person: _____________________________________________________________

Printed Name: ___________________________________________________ Date: ___________________________

FINANCIAL POLICY for Professional Foot & Ankle Centers, P.C.

.

(LOGO and PHYSCIAN NAMES)

CONSENT FORM for Treatment, Payment, and Healthcare Operations

Welcome and thank you for choosing Professional Foot & Ankle Centers, P.C. We are committed to providing you with the highest quality medical care in an efficient, timely, and effective manner. If you have any questions, please feel free to discuss them with our staff.

1. Consent for Treatment: I hereby authorize the podiatrists and staff of Professional Foot & Ankle Centers, P.C. to prescribe, administer, and perform such physical examinations, radiology examinations, laboratory tests, anesthesia, medications, durable medical equipment, hospital care, procedures and surgery as necessary or advisable in the diagnosis and treatment of my condition. I understand that the practice of medicine and surgery is not an exact science and acknowledge that no guarantees have been or will be made regarding the results of examinations or treatments in this clinic.

2. Assignment of Benefits: In consideration of any services rendered to me by Professional Foot & Ankle Centers, P.C., I hereby authorize and assign any and all reimbursement pertaining to said services to be made on my behalf and paid directly to Professional Foot & Ankle Centers, P.C. If my insurance benefits are provided to me through Medicare, I hereby authorize and assign any and all reimbursement made under my Medicare plan which pertains to any services provided to me by Professional Foot & Ankle Services, P.C.

3. Authorization to Release Information: I authorize Professional Foot & Ankle Centers, P.C. to release and disclose any Private Health Information about me that pertains to any and all medical care, tests, treatment, or advice that was rendered to me by the podiatrists and/or staff of Professional Foot & Ankle Centers, P.C. to any physicians, practitioners, insurance companies, third party payers, authorized agents, claims review organizations, support staff or facility involved in my plan of care or transfer of care and/or Medicare in order to process a claim and/or payment on my behalf.

4. HIPPA Notice of Privacy Practices: I acknowledge that a copy of the Professional Foot & Ankle Centers, P.C. HIPPA Notice of Privacy Practices will be made available to me at my request, and that I have read, or had the opportunity to read if I so chose, and understand the Notice.

5. Payment Agreement: I understand that by providing a valid and current insurance card prior to services being rendered, Professional Foot & Ankle Centers, P.C. will file a claim to my insurance company but that does not guarantee payment which ultimately I am responsible for. I hereby accept and assume financial responsibility for any covered or non-covered services rendered to me and will be responsible for any services that are unpaid as a result of not providing Professional Foot & Ankle Centers, P.C. with a valid referral. If there are any questions, problems, or delays regarding my coverage and or benefits, I understand that it is my responsibility to solve these issues with my insurance carrier and the billing office administrator. Deductibles, co-payments, and payment for non-covered services will be due at the time of service.

Please sign below if you have read, understand and agree to the above five statements.

Signature of Patient or Responsible Person:________________________________________________________________

Printed Name: _________________________________________________________ Date: _______________________

DAVISON: 605 South State Road • Davison, MI 48423 • (P) 810.653.9060 • (F) 810.658.2248LAPEER: 1390 North Main Street • Lapeer, MI 48446 • (P) 810.664.1250 • (F) 810.664.0315


CONSENT FORM fo r Trea tmen t , Paymen t and Hea l t hca re Opera t i on s





mark r. williams, dpm, facfas christopher t. … · 2017-10-31 · primary care physician: ......

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