PatientPop



____________Family Podiatry Center____________________________________?????? Advanced Foot Care ?????????????????????? ?William J. Lehrich, D.P.M., Inc ?????????????????????? ?DIPLOMATE, AMERICAN BOARD OF PODIATRIC SURGERY Date: _______________________?????????????????Referred By: __________________________?????? Male ( )Patient Name: _____________________________________________________ ?Female ( )??????????????????????????(First) ???????????????????????????(Middle) ??????????????????????????????(Last)DOB: __________________ Social Security Number_____________________________Home Address: ________________________________City: ______________Zip:________Home Phone: ________________________ Cell phone: _____________________________Email Address: ________________________________________ (For appointment reminder only)Employer: ________________________________Work Phone _______________________Employer’s Address: _________________________________________________________Spouse: ______________________Spouse’s Employer: _____________________________Spouse’s Work Phone: _________________Employer Address: _______________________ Emergency Contact: _________________________Phone: __________________________Address: ___________________________________________________________________Primary Care Physician______________________?Phone: __________________________Address of Primary Care Physician: _____________________________________________Name of Insurance Carrier: ______________________________Phone:________________Billing Address: _____________________________________________________________Name of Person Insured: ________________________ Subscriber ID#:________________Reason for visit: _____________________________________________________________Accident/Personal Injury (Circle one) Yes ( ?) ??No ( ?) ??Date of Injury: _________________I AUTHORIZE PAYMENTS OF MEDICAL BENEFITS BE MADE DIRECTLY TO THE PHYSICIAN PROVIDER FOR SERVICES RENDERED. I AUTHORIZE ANY INSURANCE COMPANY, OR ORGANIZATION, EMPLOYER, HOSPITAL, OR PHARMACIST TO RELEASE ANY INFORMATION TO THIS CLAIM AND THE EXPENSES REPORTED. IT IS OUR POLICY TO BILL YOUR INSURANCE COMPANY AS A COURTESY TO YOU. WE WILL WAIT A PERIOD OF 30 DAYS FOR YOUR INSURANCE COMPANY TO PAY US. YOUR INSURANCE MAY ONLY PAY FOR SERVICES THAT THEY DETERMINE TO BE “REASONABLE AND NECESSARY.” WE DO REQUIRE THAT YOUR CO-PAYMENT BE PAID NOW.Date: _______________________________ ?????Signature: ________________________________________San Leandro Surgery Center Building, 15035 E 14th St., Ste A, San Leandro, CA 94578 (510) 278-9350Monteagle Medical Center of St. Luke’s Hospital, 1580 Valencia St., Suite 109, San Francisco, CA 94110 (415)285-7711 FAMILY PODIATRY CENTER, Foot and Ankle Medicine & SurgeryPatient Name: ________________________________________________DOB:______________________Reason for the visit (Nature of your foot pain or problem):_______________________________________Location on Foot or Leg: ? □Forefoot/Toes ???□Middle Foot □Back part of FootCheck all that applies □Ankle ???□?Top □Bottom □Outer Side ? ? □?Inner Side How Long Has This Bothered You? ____________________________________________________How Did This Begin? _______________________________________________________________What Course has it Taken? ___________________________________________________________What aggravates it? _________________________________________________________________What makes it feel better? ___________________________________________________________What Have You Done to Relieve the Condition?__________________________________________General Health: If you have had or have any of the following, check all that apply:□Measles □Hip Problems □Pain, cramps, swelling, tingling □Mumps □Ankle Problems ?????? ?□Burning or Numbness in Feet□Chickenpox □Skin Problems ?????????????? ? □Burning or Numbness in Legs□Scarlet Fever □Bone Fracture ???This usually happens:□Headache □Pneumonia□after walking a block□Lower Back Pain???? ?□Bruise easily □while lying in bed□Neck Pain □Breath shortness on exertion □after being on feet□HIV ??How long does it last?___________________________________Can you take aspirin? ____________ Have you had a local anesthetic (such as for dental work)? _________Did you have any problems with it? __________________________________________________________Past Surgeries or Hospitalization: ____________________________________________________________WOMEN: Are you, to your knowledge, pregnant? □Yes ?????????□NoALLERGIES:Are you allergic or sensitive to: ??□Penicillin □ Novacaine □Anesthetics????? □Adhesive Tape □Iodine □Metal???????? □Drugs:____________ ????????????? □Other:____________???????? □I am NOT allergic to anything that I know of.Ethnicity: _________________ Race: _______________________ Language:______________________Smoke: □Yes □No □Former?□Never HEALTH HISTORY:Have you ever had any of the following (Please check all that apply)□Diabetes □Epilepsy□Heart Trouble ? □ Nerve Disease□Blood vessel disease □Nervous Condition□High Blood Pressure □Bone disease□Kidney trouble □Varicose veins□Liver problems □Arthritis□Anemia □Cancer□Lung disease □Rheumatic fever□Blood disease □Asthma□Lymph Disease □Gout I certify that the above information is accurate and true to the best of my knowledgeSignature: ____________________________________________ Date: _____________________________ NOTICE OF PRIVACY PRACTICE ACKNOWLEDGEMENT???Dr. William J. Lehrich DPM???????Family Podiatry Center?????15035 E 14th Street Ste A ???????San Leandro, Ca 94578?????????Tel (510)278-9350 Fax (510)481-7490I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPPA”) I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in the treatment directly and indirectly.Obtain payment from third-party payerConduct normal healthcare operations such as quality assessments and physician certification.I have received, read and understand your Notice of Privacy Practices containing a more complete description of the used and disclosure of my health information. I understand that this organization had the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Private Practices.I understand that I might request in writing that you restrict how my private information is used pr disclosure to carry out treatment, payment or healthcare operations. I also understand you are not required to agree to my request restrictions. But if you do agree then you are bound to abide by such restrictions.Patient Name:__________________________________________________Signature: __________________________________________________Date: __________________________________________________________________________________________________________________________OFFICE USE ONLY I attempted to obtain the patient’s signature in acknowledgment, but was unable to do so as documented below:Date: _____________ Initial:__________________ Reason:_________________________FAMILY PODIATRY CENTER15035 E 14th St San Leandro, CA 94578 (510)278-9350 MEDICINE LISTPatient Name: _____________________________________________ DOB:____________1.________________________________________________________________________2.________________________________________________________________________3._________________________________________________________________________4._________________________________________________________________________5._________________________________________________________________________6._________________________________________________________________________7.________________________________________________________________________8._________________________________________________________________________9._________________________________________________________________________10.________________________________________________________________________11.________________________________________________________________________12.________________________________________________________________________13.________________________________________________________________________14.________________________________________________________________________15.________________________________________________________________________16.________________________________________________________________________17.________________________________________________________________________18.________________________________________________________________________ ................
................

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

Google Online Preview   Download