Please read our Payment Policy by clicking this link: Payment Policy, and then fill out the form below.

You may also print the PDF application if you prefer by clicking here: PDF

*If patient is under 18, we will need the following information from a parent or guardian:

Referral Information

Who may we thank for referring you?

Primary Care Physician

To facilitate sharing of information related to your care, please provide the following information.

Physician

Primary Physician

Insurance Plan

Office Phone Number

Family/Friend

Date of Last Visit?

Former Patient

Do You Reside in a Hospice?

Do You Reside in a Nursing Home?

Other

Name of Residence


Insurance Information


Emergency Contact

Name

Relationship

Primary PhoneNumber

Secondary PhoneNumber


What Brought You in Today?

What is the reason for your visit today?

When is it problematic?

What makes it better/worse?

How have you treated it?

Have you ever been to a podiatrist?

If yes, please list the podiatrist?


Podiatric History

Please indicate your current and past foot problems:

Lifestyle

Do you smoke/ use tobacco?

What is your activity level?

Do you drink alcohol?

Do you exercise/participate in athletic activities?

Do you drink coffee/other caffeinated drinks?

What activities do you participate in and how frequently?

Do you travel frequently?

Do you use recreational drugs?


Allergies - Please list any and all allergies that you have. Check none if you have no known allergies:

Other

Please indicate the severity of your reaction to each allergy indicated

What happens with each allergic reaction?


Medical History - Please indicate if you have had any of the following conditions:

Other

Medications

Surgeries and Hospitalizations

Please list all medications taken (unless you have provided a separate list)

Please list all surgeries that you have had

I brought a list and gave it to the front desk

Please list any other hospitalization(s) that were not for the surgeries listed

I take oral contraceptives

I take blood thinners/anti-coagulates

Pharmacy Name

Pharmacy Number

Other Health Issues

Is there anything else you would like to share with your doctor regarding your health or medications that is not covered above


Assignment & Release

and sign directly to Community Foot Specialists all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the Doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
I request that payment of authorized Medicare benefits be made on my behalf to Community Foot Specialists for any services furnished me by my physician. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits payable for related services. I understand my signature requests that payment be made and authorize release of medical information necessary to pay the claim. If “other health insurance” is indicated in item 9 of the HCFA-1500 for, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes release for the information to the insurer or agency shown. In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, 20%, and non-covered services. Coinsurance, 20% and the deductible are based upon the charge determination of the Medicare carrier.
By typing your name, you agree that this electronic signature shall carry the same weight as your handwritten signature for this agreement.

Consent

I certify that the above information is true and correct to the best of my knowledge. I give permission to the doctor to administer and perform such procedures as may be deemed necessary in the diagnosis and/or treatment of my conditions. I give permission to acquire audiovisual documentation for diagnostic and treatment purposes. I understand that other practitioners such as surgical assistants, surgical residents, physician assistants, nurses and other staff may assist the doctor in performing my treatment and I give my permission for them to do so.

By typing your name, you agree that this electronic signature shall carry the same weight as your handwritten signature for this agreement.

Payment Policy & Privacy Practices

Notice of Privacy Practice

Health Information Use and Disclosure. Community Foot Specialists understands that medical information about you and your health is personal and we are committed to protecting that information. With that understanding, we will use and disclose your health information expressly for the following purposes: to treat you, to assist other healthcare providers in treating you, to allow insurance companies to process claims for services rendered to you, to obtain payment for services rendered to you and for certain limited operational activities, such as quality assessment, licensing, accreditation and training of students. Except for the aforementioned reasons, we will not use or disclose your health information without your written authorization. We reserve the right to change this notice and will post a copy of the current (dated) notices in effect in our facility.

Additional Disclosure Authority. In addition to the allowable disclosures described in the State of OH Privacy Practices, I hereby specifically authorize disclosure of my protected health care information to the person(s) indicated below. This can include: any/all members of immediate family, spouse, employer, school, or any other person.

Patient Rights

As our patient, you have the following rights:

  • To have access to inspect and/or obtain a copy of your health information that may be used to make decisions about your care.
  • To receive an accounting of certain health information disclosures we have made.
  • To request restrictions pertaining to how health information is used and disclosed for treatment payment or health operations.
  • To request that we communicate with you in confidence; in a certain way or at a certain location. For example, you can ask that we only contact you by mail or at work.
  • To request that we amend your health information if you feel medical information we have about you is incorrect or incomplete. To receive notice of our privacy practices by requesting a paper copy at any time.

Acknowledgement of Payment Policy/Notice of Privacy Practices

Payment Policy

I have read and fully understand the payment policy of Community Foot Specialists. I acknowledge my rights and responsibilities and agree to act in accordance with the policy set forth. I understand that if I fail to comply with the policy, Community Foot Specialists reserves the right to dismiss me from the practice.

Privacy Practices

I acknowledge I was provided a copy of the Notice of Privacy Practices and have read (or had the opportunity to read if I so chose) and understood the Notice.

By typing your name, you agree that this electronic signature shall carry the same weight as your handwritten signature for this agreement.