jacobjacob foot and ankle associates division of new jersey podiatric physicians & surgeons...

JACOBFOOTANDANKLEASSOCIATESADIVISONOFNEWJERSEYPODIATRICPHYSICIANS&SURGEONSGROUP,LLC

Thankyouforchoosingourofficetoprovideyouwithmedicalcare.Wearecommittedtoservingyouwithskillandhighqualitycare.Themedicalservicesprovidedbyourofficeareservicesyouhaveelectedtoreceivewhichmayimplyafinancialresponsibilityonyourpart.INSURANCE:Weparticipateinmostinsuranceplans.Ifyouarenotinsuredbyaplanweparticipatewith,paymentinfullisexpectedateachvisit.Ifyouareinsuredbyaplanweparticipatewithbutdonothaveanup-to-dateinsurancecard,paymentinfullforeachvisitisrequireduntilwecanverifyyourcoverage.Knowingyourinsurancebenefitsisyourresponsibility.Pleasecontactyourinsurancecompanywithanyquestionsyoumayhaveregardingyourcoverage.MEDICARE:WeareaparticipatingMedicareprovider.Medicareaswellasyoursecondaryinsurance(ifany)willbebilledforyou.However;thatdoesnotmeanthatallservicesarecovered.Patientsareresponsibleforpayingtheirannualdeductibleifithasnotyetbeenmet.Youarealsoresponsibleforanycoinsurance,whichisusually20%oftheallowedamountforanitemorservice.SECONDARYINSURANCE:Yourmedicalclaimwillbeforwardedtoyoursecondaryinsurance(ifany)afterpaymentand/orexplanationofbenefits(EOB)isreceivedfromyourprimaryinsurancecompany.COPAYMENTSANDDEDUCTIBLES:Allco-paymentsanddeductiblemustbepaidatthetimeofservice.Thisarrangementispartofyourcontractwithyourinsurancecompany.Failureonourparttocollectco-paymentsanddeductiblesfrompatientscanbeconsideredfraud.Pleasehelpusinupholdingthelawbypayingyourco-paymentateachvisit.SELFPAY:Paymentinfullisdueatthetimeofserviceifyoudonothavehealthinsurance.NON-COVEREDSERVICES:PleasebeawarethatsomeoftheservicesyoureceivemaynotbecoveredornotconsideredreasonableornecessarybyMedicareorotherinsurers.Youareresponsibleforpaymentoftheseservices.REFERRALS/AUTHORIZATIONS:Wearerequiredtofollowtheguidelinesofyourmanagedcareplanwhichmandatesusthatwhenyouvisitaspecialistsuchasours,youmusthaveareferralfromyourprimarycarephysicianpriortoseekingspecialtycare.Obtainingreferralsfromyourprimaryphysicianandkeepingtrackofyourvisitsisyourresponsibility.Ifyoudonothaveavalidreferralatthetimeofyourvisit,yourappointmentwillberescheduled.CLAIMSUBMISSION:Wewillsubmityourclaimsandassistyouinanywaywereasonablycantohelpgetyourclaimspaid.Yourinsurancecompanymayneedyoutosupplycertaininformationdirectly.Itisyourresponsibilitytocomplywiththeirrequest.Pleasebeawarethatthebalanceofyourclaimisyourresponsibility.Yourinsurancebenefitisacontractbetweenyouandyourinsurancecompany.PATIENTBILLING:Youwillbesentuptothreenoticesforyourfinancialresponsibility(co-insurance,deductible)afterpaymentand/orexplanationofbenefits(EOB)isreceivedfromyourinsurancecompany/companies.Afterthethirdandlastnotice,youraccountmaybeforwardedtocollectionswithinterestaccruingonbalance.Itisalsoyourresponsibilitytopayfortheinterestaccruedifsenttocollections.Pleaseletthebillingofficeknowifyouhaveanydifficultiesresolvingyourbill.Paymentarrangementscanbemadeonacasebycasebasis.Weacceptthefollowingpaymentmethods:CASH,CHECK,VISA,MASTERCARD,DISCOVER,AMERICANEXPRESS,MONEYORDER,BANKCHECK.Anadditional$25.00willbeaddedtoyourstatementifthecheckisreturnedforinsufficientfunds.Intheeventthatyourinsurancecompanyshouldhappentosendpaymenttoyou,thepatient,weexpectthatyouwouldforwardittoourofficetobeappliedtoyourbalance.IhavereadtheabovepolicyregardingmyfinancialresponsibilitytoJACOBFOOTANDANKLEASSOCIATESformedicalservicesprovided.IagreetopayJACOBFOOTANDANKLEASSOCIATESanybalanceunpaidbymyinsurancecarrierformyselforthebelownamedperson.AssignmentofBenefitsI,theundersigned,certifythatI(ormydependent)havecoveragewithmyinsuranceaspresentedandassigndirectlyto,JACOBFOOTANDANKLEASSOCIATES,adivisionofNewJerseyPodiatricPhysicians&SurgeonsGroup,allinsurancebenefits,payabletomeforservicesrendered.IunderstandthatIamresponsibleforpaymentofdeductibles,co-payments,and/ornon-coveredservices.Iherebyauthorizethedoctortoreleaseallinformationnecessarytosecurepaymentofbenefits.IauthorizeRELEASEOFMEDICALINFORMATIONtomyinsurancecarrier,orrequestedphysiciantoprovidecontinuityofcare.Iauthorizetheuseofthissignatureonallinsurancesubmissions.PRINTPatientName:__________________________________ Signature:_____________________________________________FINANCIALLYRESPONSIBLEPARTY:PRINTName:_______________________________________ Signature:____________________________________________RelationshiptoPatient:_______________________________ Date:________________________________________

JACOBFOOTANDANKLEASSOCIATESDIVISION OF NEW JERSEY PODIATRIC PHYSICIANS & SURGEONS GROUP, LLC

PATIENT HIPAA ACKNOWLEDGEMENT AND DESIGNATION DISCLOSURE FORM

I. Acknowledgement of Practice’s Notice of Privacy Practices:

By subscribing my name below, I acknowledge that I was provided a copy of the Notice of Privacy Practices (NPP), and that I have read (or had the opportunity to read if I so chose) and understand the Notice of Privacy Practices (NPP) and agree to its terms.

________________________________ ____________ ________________________________

Name of Patient Date of Birth Signature of Patient/Parent/Guardian

II. Designation of Certain Relatives, Close Friends and other Caregivers as my Personal

Representative: I agree that the practice may disclose certain of my health information to a Personal Representative of my choosing, since such person is involved with my health care or payment relating to my health care. In that case, the Physician Practice will disclose only information that is directly relevant to the person’s involvement with my health care or payment relating to my health care.

Print Name: Last four digits SSN (required): Print Name: Last four digits SSN (required): Print Name: Last four digits SSN (required):

III. Request to Receive Confidential Communications by Alternative Means: As provided by Privacy Rule Section 164.522(b), I hereby request that the Practice make all communications to me by the alternative means that I have listed below. Home Telephone Number: Written Communication Address:

____ OK to leave message with detailed information OK to mail to address listed above Leave message with call back numbers only E-mail me at: Work Telephone Number: Fax Number: ______________________________ ___________________________________ OK to leave message with detailed information OK to Fax at the number listed above Leave message with call back numbers only E-mail me at: Other:

____________________________________ ___________________________________ Name of Patient (Printed) Signature of Patient/Parent/Guardian ____________________________________ ___________________________________ Witness signature Date

JACOBFOOTANDANKLEASSOCIATESDIVISIONOFNEWJERSEYPODIATRICPHYSICIANS&SURGEONSGROUP,LLC

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PATIENTINFORMATIONFORM

(PLEASEPRINTCLEARLY)DATE:________________________ SOCIALSECURITY#:____________________________________PATIENTNAME:___________________________________________________________DATEOFBIRTH:_________________________AGE:____SEX:MFPRIMARYLANGUAGE:____________________________RACE:______________ETHNICITY:____________ADDRESS:__________________________________________________CITY/STATE:___________________________ZIP:_____________HOMEPHONE:(________)_________-___________CELLPHONE:(________)________-____________EMAILADDRESS:___________________________________________________________(WILLNOTBESHARED)

EMPLOYER:___________________________________________________________WORKPHONE:(________)________-____________ EMERGENCYCONTACT:________________________________RELATIONSHIP:_______________PHONE:(______)______-________PRIMARYCAREDOCTOR:_____________________________________________________DATELASTSEEN________________________PHONE:(_______)________-________ADDRESS:______________________________________CITY/STATE:____________________PHARMACY:_____________________________LOCATION:______________________________PHONE:(______)_______-___________WHOISRESPONSIBLEFORPAYMENT?_________________________________________RELATIONSHIP:________________________ADDRESS:____________________________________________CITY/STATE:________________________________ZIP:______________PHONE:(_______)_______-__________WHOREFERREDYOUTOUS?_____________________________________________________INSURANCEINFORMATIONPRIMARYINSURANCECOMPANYNAME:_______________________________________________________________________________ADDRESS:_____________________________CITY/STATE:____________________ZIP:_________PHONE:(______)______-________INSUREDNAME:____________________________DATEOFBIRTH___________________EMPLOYER___________________________ID#___________________________________________________GROUP#_____________________________________________________SECONDARYINSURANCECOMPANYNAME:____________________________________________________________________________ADDRESS:______________________________CITY/STATE:_________________ZIP:_________PHONE:(______)_______-_________INSUREDNAME:_________________________________DATEOFBIRTH______________EMPLOYER___________________________ID#___________________________________________________GROUP#_____________________________________________________


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PATIENTNAME:__________________________________________MEDICATIONSPLEASELISTALLMEDICATIONSYOUARECURRENTLYTAKING(INCLUDEPRESCRIPTIONS,OVER-THE-COUNTERMEDSANDHERBALSUPPLEMENTS):MEDICATIONNAME DOSE HOWOFTENDOYOUTAKE?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________PLEASELISTALLPRIORSURGERIES:TYPEOFSURGERY DATE TYPEOFSURGERY DATE________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________PLEASELISTALLPRIORHOSPITALIZATIONS(OTHERTHANFORSURGERY):REASONFORHOSPITALIZATION DATE REASONFORHOSPITALIZATION DATE_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________SOCIALHISTORYMARITALSTATUS:cSINGLEcMARRIEDcPARTNEREDcSEPARATEDcDIVORCEDcWIDOWEDUSEOFALCOHOL:cNEVERcNOLONGERUSEcHISTORYOFALCOHOLABUSE

cCURRENTUSE-TYPE__________________cRAREcOCCASIONALcMODERATEcDAILYUSEOFTOBACCO:cNEVERcQUIT–HOWLONGAGO?_________cSMOKE____PACKS/DAYFOR____YEARSUSEOFRECREATIONALDRUGS:cNEVERcQUIT–HOWLONGAGO?_________TYPE_______________________

cCURRENTUSE-TYPE_______________cRAREcOCCASIONALcMODERATEcDAILY

FAMILYHISTORYDOYOUHAVEAFAMILYHISTORYOF:cDIABETES:TYPE1ORTYPE2cCANCERcHEARTDISEASEcHIGHBLOODPRESSUREcSTROKEcCORONARYARTERYDISEASEcBLEEDINGDISORDERcRHEUMATOIDARTHRITIScOTHER________________________________________________________________________


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PATIENTNAME:__________________________________________YOURMEDICALHISTORYALLERGIES:cMEDICATIONS_______________________________________________________________________________

cANESTHESIA_________________________________cFOODS____________________________________cTAPEcLATEXcSHELLFISHcIODINEcOTHER_____________________________________

cNONEKNOWNREACTION:__________________________________________________________________________________________________HAVEYOUEVERHADANYOFTHEFOLLOWING?ACIDREFLUX Y N FIBROMYALGIA Y N NEUROPATHY Y NANEMIA Y N GOUT Y N OPENSORES Y NARTHRITIS Y N HEARTATTACK Y N PNEUMONIA Y NASTHMA Y N HEARTDISEASE/FAILURE Y N POLIO Y NBACKTROUBLE Y N HEPATITIS Y N RHEUMATICFEVER Y NBLADDERINFECTIONS Y N HIV+/AIDS Y N SICKLECELLDISEASE Y NABNORMALBLEEDING Y N HIGHBLOODPRESSURE Y N SKINDISORDER Y NBLOODCLOTS Y N KIDNEYDISEASE Y N SLEEPAPNEA Y NBLOODTRANSFUSION Y N LIVERDISEASE Y N STOMACHULCERS Y NBRONCHITIS/EMPHYSEMA Y N LOWBLOODPRESSURE Y N STROKE Y NCANCER Y N MIGRAINEHEADACHES Y N THYROIDDISEASE Y NDIABETES:TYPE1ORTYPE2(CIRCLE)

Y N MITRALVALVEPROLAPSE Y N TUBERCULOSIS Y N

OTHERCONDITIONS: CURRENTPROBLEMWHATSPECIFICPROBLEMBRINGSYOUTOOUROFFICETODAY?___________________________________________________________ HOWLONGAGODIDTHISPROBLEMFIRSTSTART?__________DAYS/WEEKS/MONTHS/YEARSDIDYOURPAINORPROBLEM:cBEGINALLOFASUDDEN cGRADUALLYDEVELOPOVERTIME HOWWOULDYOUDESCRIBEYOURPAINORSYMPTOM?cNOPAINcSHARPcDULLcACHINGcBURNING

cRADIATINGcITCHINGcSTABBINGcOTHER________________________________________________SINCETHETIMEYOURPAINORPROBLEMBEGAN,HASIT:cSTAYEDTHESAMEcBECOMEWORSEcIMPROVEDWHATMAKESYOURPAINORPROBLEMFEELWORSE?cWALKINGcSTANDINGcDAILYACTIVITIES

cRESTINGcDRESSSHOEScHIGHHEELScFLATSHOEScANYCLOSEDTOESHOEcRUNNINGcOTHER________________________________________________________________________________

WHATMAKESYOURPAINORPROBLEMFEELBETTER?____________________________________________________________WHATTREATMENTSHAVEYOUHADFORTHISPROBLEM?_________________________________________________________WASTHISPROBLEMCAUSEDBYANINJURY?cYEScNO(DESCRIBE)___________________________________________


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IFYES,WASITAWORK-RELATEDINJURY?cYEScNOPATIENTNAME:________________________________________E-PRESCRIBINGCONSENTE-PRESCRIBINGISDEFINEDBYAPHYSICIANSABILITYTOELECTRONICALLYSENDANACCURATE,ERRORFREE,ANDUNDERSTANDABLEPRESCRIPTIONDIRECTLYTOYOURPHARMACY.CONGRESSHASDETERMINEDTHATTHEABILITYTOELECTRONICALLYSENDPRESCRIPTIONSISANIMPORTANTELEMENTINIMPROVINGTHEQUALITYOFPATIENTCARE.E-PRESCRIBINGGREATLYREDUCESMEDICATIONERRORSANDENHANCESPATIENTSAFETY.THEMEDICAREMODERNIZATIONACT2003,LISTEDSTANDARDSTHATHAVETOBEINCLUDEDINANE-PRESCRIBINGPROGRAM.THESEINCLUDE:(1)FORMULARYANDBENEFITTRANSACTIONS,WHICHGIVESTHEPRESCRIBERINFORMATIONABOUTWHICHDRUGSARECOVEREDBYADRUGBENEFITPLAN;(2)MEDICATIONHISTORYTRANSACTIONS,WHICHPROVIDESTHEPHYSICIANWITHINFORMATIONABOUTMEDICATIONSTHEPATIENTISALREADYTAKINGTOMINIMIZEADVERSEDRUGEVENTS.IAUTHORIZEJACOBFOOTANDANKLEASSOCIATESDIVISIONOFNJPPSG,TOVIEWMYEXTERNALPRESCRIPTIONHISTORYVIAELECTRONICE-PRESCRIBINGSERVICES.IUNDERSTANDTHATPRESCRIPTIONHISTORYFROMMULTIPLE,OTHERUNAFFILIATED,PROVIDERS,INSURANCECOMPANIES,PHARMACIESANDPHARMACYBENEFITMANAGERSMAYBEVIEWABLEBYTHEPROVIDERSANDSTAFFOFJACOBFOOTANDANKLEASSOCIATES,DIVISIONOFNJPPSG,ANDITMAYINCLUDEPRESCRIPTIONSBACKINTIMEFORSEVERALYEARSANDMAYINCLUDEPRESCRIPTIONSTOTREATHIV,SUBSTANCEABUSEANDPSYCHIATRICCONDITIONS.IFAPPLICABLE,IUNDERSTANDTHATMYPRESCRIPTIONHISTORYWILLBECOMEPARTOFMYRECORDATTHISPRACTICE.UNDERSTANDINGALLOFTHEABOVE,IHERBYPROVIDEINFORMEDCONSENTTOJACOBFOOTANDANKLEASSOCIATES,DIVISIONOFNJPPSG,TOENROLLMEINTHEE-PRESCRIBEPROGRAM.THISCONSENTWILLREMAINENFORCEDUNTILREVOKEDORCHANGED._______________________________________________________________________________________________________PATIENTSIGNATUREPARENT/LEGALGUARDIANSIGNATUREICERTIFY,TOTHEBESTOFMYKNOWLEDGE,IHAVEANSWEREDTHEQUESTIONSONTHISFORMACCURATELY.IUNDERSTANDTHATPROVIDINGINCORRECTINFORMATIONCANBEDANGEROUSTOMYHEALTH.IUNDERSTANDTHATITISMYRESPONSIBILITYTOINFORMTHEDOCTORANDOFFICESTAFFOFANYCHANGESINMYMEDICALSTATUS.IGIVEPERMISSIONTOTHEDOCTORSATJACOBFOOTANDANKLEASSOCIATES,ADIVISIONOFNEWJERSEYPODIATRICPHYSICIANSANDSURGEONSGROUP,LLC,TOADMINISTERANDPERFORMANYDIAGNOSTIC,THERAPEUTICAND/OROPERATIVEPROCEDURESASMAYBEDEEMEDMEDICALLYNECESSARYINDIAGNOSISAND/ORTREATMENTOFMYCONDITION.PATIENT/MINORSUNDERTHEAGEOF18,WILLNOTBETREATEDWITHOUTAPARENTORLEGALGUARDIANPRESENT.IFANOTHERFAMILYMEMBER,CARETAKERORFRIEND,OVERTHEAGEOF18WILLBEPRESENT;WRITTENCONSENTFROMTHEPARENT/LEGALGUARDIANSTATINGASSUCHMUSTBEPRESENTEDATTHETIMEOFTHEAPPOINTMENT.THANKYOU.___________________________________________________ __________________________________________________PRINTNAMEOFPATIENT PRINTPARENT/LEGALGUARDIAN___________________________________________________ ____________________________________________________PATIENTSIGNATURE SIGNATUREPARENT/LEGALGUARDIAN____________________________________________________DATE

jacobjacob foot and ankle associates division of new jersey podiatric physicians & surgeons...

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