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
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