EUGENE J



EUGENE J. CARR, D.P.M., P.A. MR# _______________

WELCOME TO OUR OFFICE

Eugene J. Carr, Jr. D.P.M. Peter J. Luthringer, D.P.M.

Diplomate American Board Diplomate American Board

of Podiatric Surgery of Podiatric Surgery

Patient's Name _________________________________________________ Age ___________

Birth Date _________________________ Gender ____________ Marital Status - S M W D

Social Security # ___________________________ Occupation ________________________

Employer _______________________________ Business Phone # ______________________

Name of Spouse __________________________ Spouse's Birth Date ____________________

Spouse's SS#___________________________________

Person Responsible for Bill ______________________________________________________

BILLING INFORMATION: Please send patient bills to: Local Address / Northern Address

Circle one

LOCAL ADDRESS :

Street ______________________________________________ APT # __________________

City ______________________________ State _________________ Zip _______________

Phone # _______________________________ Cell # ________________________________

NORTHERN ADDRESS :

Street ______________________________________________APT # ____________________

City _____________________________ State __________________ Zip _______________

Phone # ________________________________

Privacy Information Preferences

Do you want to be exempt from public reporting? Yes No Can we send mail to the address on file? Yes No

Can we call the phone number on file? Yes No Can we leave voicemail on machine? Yes No

Will you allow us to send internet based (e-mail) delivery of reminders? _Yes _No

If yes, please provide your e-mail address:

_________________ _

Who can we leave messages with? _Wife _Husband _Daughter _Son _Other

Name(s):____________________________

Patient’s Name____________________________________________________________

PERMISSION TO TREAT

I hereby give my permission to Dr. Eugene Carr, Jr. and/or Dr. Peter Luthringer and their staff, to administer treatment, and to perform such procedures as may be deemed necessary in the diagnosis and/or treatment of the condition.

SIGNATURE: __________________________________Date: ______________________

FINANCIAL POLICY

I am aware that I am ultimately responsible for payment of the services I receive, regardless of insurance, regardless of outcome. I understand that additional charges will be added to my account for returned checks, and that a service charge of 1.5% monthly (18% yearly) may be applied to all past due accounts. I understand that delinquent accounts may be referred to a collection agency and that I will be responsible for the collection costs. In this case, a collection fee of 30% of the outstanding balance will be added to your account and shall become part of the total amount due. I may also be responsible for any/all attorney fees and court costs.

SIGNATURE:______________________________DATE:_____________________

INSURANCE / MEDICAL RECORDS RELEASE

I authorize Eugene J. Carr, D.P.M., P.A. , Eugene J. Carr, Jr. D.P.M., Peter J. Luthringer, D.P.M., to release any and all medical records to my insurance company(s), and to my referring/family physician as deemed necessary. I authorize payment of medical insurance benefits either to myself or to the party who accepts assignment. This authorization shall be valid for services and treatment received today and all future visits/treatment.

SIGNATURE:_________________________________DATE:______________________

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I acknowledge that I have access to the Notice of Privacy Practices (located in a notebook at the check-in desk) and that I have read it, if I so choose.

_________________________________ _________________________________________

SIGNATURE Parent or Authorized Representative (if applicable)

_________________________________ __________________

PATIENT NAME (please print) DATE

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download