WELCOME TO OUR PRACTICE PATIENT INFORMATION

All information will be confidential.

We are not a Workers Compensation Prollider. We do not Ole Texas Workers Comp cases or motorcycle/motor lIehicle accident claims.

Pruient Nwme ____________~~~~~--------------------- Age: lasl. First, Middle ---------------------­

. Social Security # _____ Date of Birth: ___________________________

Gender: Male 0 Female C Marital Status: Single 0 Married C Separated C Divorced Cl Widowed Cl

Address_______________________________ City__________ State_____ Zip____

HomePhone#___________________~--- Cell Phone # ___________________________

Work Phone # _________________________ Email: _____________________________

Employer_______________________ Position_____________________________

Primary insured's name if other than patient _______________________ D.O.B. __________________

Pharmacy: ___________________________________ Location: _________________________

Who is Your Primary Care Doctor? _____________________________________________________

Whom may we thank for referring you? (Please Mark Appropriate Box Below)

Insurance PianO Friend/FamilyC DoctorC__________________ Phone BookO Previous patientCl

Other__________________________________________GoogleC YeipO FacebookC

EmergencyContact: ___________________________________________D.O.B. __________________

Phone: ___________________________________Relationship:

To the best of my knowledge, the questions on the forms have been accurately answered. I understand that providing incorrect information can be dangerous to my health. II is my responsibility to inform the doctor's office of any changes in my medical status. I also authorize the healthcare staff to perform the necessary services I may need.

Signature of Patient, Parent or Guardian D.O.B. Date

Patient Financial Policy

Your understanding of our financial policies is an essential element of your care and treatment. If you have any questions, please discuss them with our front office staff.

• As our patient, you arc responsible for all authorization/referrals needed to seek treatment in this office.

• We are not a worker's compensation insurance provider. We do not file Texas Worker's Comp cases or motorcycle/motor vehicle accident claims. I understand that I am responsible for any charges owed to this office due to my care at the time of service.

• Unless other arrangements have been made in advance by you, or your health insurance carrier, payment for office services are due at the time of service. We will accept VISA, MASTERCARD, DISCOVER, AMERICAN EXPRESS, cash or check.

• Your insurance policy is a contract between you and your insurance company. As a courtesy, we will file your insurance claim for you jf you assign the benefits to the doctor. In other words, you agree to have yoU\' insurance company pay the doctor directly. If your insurance company does not pay the practice within a reasonable period, we will have to look to you for payment.

• We have made prior arrangements with insurers and other health plans to accept an assignment of benefits. We will bill those plans with we have an agreement and will only require you to pay the co­pay/co-inslll'ance/deductible at the time of service.

• If you have insurance coverage with a plan with which we do not have a prior agreement, we will prepare and send the claim the claim for you on an unassigned basis. This means your insurer will send the payment directly to YOLl. Therefore, all charges for your care and treatment are due at the time of service.

• All health plans are not the same and do not cover the same services. In the event your health plan determines a service to be "not covered," or you do not have authorization, you will be responsible for the complete charge. We will attempt to verify benefits for some specialized services; however, you remain responsible for charges to any service rendered.

• You must inform the office of all insurance changes and authorization referral requ irements. In the event the office is not informed, you will be responsible for any charges denied.

• There are celtain elective surgical procedures that require pre-payment. You will be informed in advance if your procedure is one of those. In that event, payment will be due two days prior to the surgery.

• Past due accounts are subject to the collection proceedings. All fees including, but not limited to collection fees, attorney fees and court fees shall become your responsibility in addition to the balance due to this office.

• There is a service fee of $25 .00 for all returned checks. Your insurance company does not cover this fee.

Signature of Patient/RespOllsible Party: ____ ______ _ ______________

Printed Name of Patient/Responsible Party: _____ ~__ _ ~_ ___ ~_ _ Date: ____ _

Name DOB ______________ Date _______ ------------~L-as-I.7Fi-~I----------------

What is your specific fool/ankle problem? _______________________________

Current Prescription Medications 1.____________________________ 2._______________________________ 3._______________________________ 4.________________________________ 5.______________________________ 6.______________________________ 7._____________________________

[J Yes [] No [J Yes [] No [J Yes [] No [J Yes [] No [J Yes [] No [J Yes [] No [J Yes [] No

Past Medical History Diabetes :# years ______

Heart Disease High Blood Pressure Arthritis: Type ______

Artificial Joints: Where? ___

Gout Alcoholism

[] Yes [J No [J Yes [J No [J Yes [J No [] Yes [J No [J Yes [J No [J Yes [] No [] Yes [] No

Asthma Aids or HIV

Allergies Penicillin Aspirin Codeine Adhesive Tape Sulfa LocaJ Anesthetic Other

[] Yes [] No [] Yes [] No

Tendency to form large scars [] Yes [] No Kidney Problems [] Yes [] No

High Cholesterol [] Yes [] No Bleeding Problems [] Yes [] No

Previous Surgeries 1. __________________________________ 2. ______________________________ 3. __________________________________

Height _______________________________

Social History Occupation Tobacco: []Never []Current []Past Quit Date __ __ Alcohol: DNever [JSocial []Daily

Weight ____________________________

Have You Experienced Any of These Symptoms Recently?

GeneraJ General good heaJth lately Fever/Chills

Respiratory Shortness of breath Past anesthesia difficulties

Cardiovascular Palpitations/ Arrythmias Chest Pain Swelling of feet or ankles

Gastrointestinal Stomach ulcers Reflux Intolerance to Aspirin/NSAIDS

[] Yes [] No [] Yes [] No

DYes [] No [] Yes [] No

[] Yes [] No [] Yes [] No [] Yes [] No

[] Yes [J No [J Yes [J No [] Yes [J No

Endocrine Excessive thirst or urination [] Yes [J No

Musculoskeletal Joint pain/stiffness [] Yes [J No

Muscle pain/cramps [J Yes [J No

Integumentary Rash or itching [] Yes [J No

Varicose Veins [] Yes [J No

Neurological Tremors [] Yes [J No

Numbness/Tingling [] Yes [J No

Hematologic/Lymphatic Bleeding tendency [] Yes [J No

Past transfusion [] Yes [J No

ALL INSURED PATIENTS

I request that payment of authorized insurance benefits be made to Steven B. Beito, DPM, J. Jacob Ransom, DPM or New Braunfels Podiatry, for any services furnished to me by that physician. I authorize any holder of medical information about me at New Braunfels Podiatry to release said information to the insurance entity requesting it.

Patient's Signature ___________ ______ Date: _____ _

Acknowledgement of Receipt of Notice of Privacy Practices

I have read a copy of the New Braunfels Podiatry Associates, LLC Notice of Privacy Practices.

Patient/Guarantor Signature: _ _ _ _ _ _ _ _ ____ Date: _______

I wish the following individual(s) to have access to my medical information:

D.O.B._____ (Name)

Staff Will Fill out This Section If Patient's Signature Not Obtained

Our office made a good faith effort to obtain Acknowledgement of Receipt of our Notices of Privacy Practices, but it could not be obtained for the following reason:

__ Patient refused to sign.

__ Emergency situations kept us from obtaining the patient's signature.

__ Language barriers kept us from obtaining the patient's signature.

Other ______________________

New Braunfels Podiatry Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MA Y BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Understanding Your Health Record/Information

Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:

• basis for planning your care and treatment

• means of communication among the many health professionals who contribute to your care

• legal document describing the care you received

• means by which you or a third party payer can verify that services billed were actually provided

• a tool in educating heath professionals;

• a s?urce of data for medical research;

• a source of information for public health officials charged with improving the health of the nation;

• a source of data for facility planning and marketing and

• a tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.

Understanding what is in your record and how your health information is used helps you to:

• ensure its accuracy

• better understand who, what, when, where and why others may access your health infonnation

• mijke more informed decisions when authorizing disclosure to others.

Your Health Information Rights:

Although YO\lr health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you . You haye the right to :

• request a restriction on certain uses and disclosures of your information

• obtain a paper copy 0 f the notice of information practices upon request

• inspect and copy your health record

• amend your health record

• obtain an accounting of disclosures of your health information

• request communications of your health information by alternative means or at alternative locations

• revoke your authorization to use or disclose health information except to the extent that action has already been taken.

Our Respon!sibilities:

This organiz~tion is required to:

• maintain the privacy of your health information

• prqvide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about yop

• abide by the terms of this notice

• notifY you if we are unable to agree to a requested restriction

• ac~ommodate reasonable requests you may have to communicate health infonnation by alternative means or at alternative locations.

We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain . Should ollr infonnation practices change, we will mail a revised notice to the address you've supplied us.

We will not use or disclose your health infonnation without your authorization , except as described in this notice.

For More Iriformation or to Report a Problem

If have quesrions and would like additional information, you may contact our office at (830) 625-1642.

If you believe your privacy rights have been violated, you can file a complaint with our office or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.

Examples of Disclosures for Treatment, Payment and Health Operations

We will use your health information for treatment. For example: Information obtained by a nurse, physician or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you . Your physician will document in your record his expectations of the members of your healthcare team. Members of your healthcare team will then record the actions they took and their observations. In that way the physician will know how you are responding to treatment.

We will also 'provide your physician or a subsequent healthcare provider with copies of various reports that should assist him/her in treating you once you're discharged from this hospital.

We will use your health information for payment. For example: A bill may be sent to you or a third party payer. The infonnation on or accompanying the bill may include infonnation that identifies you , as well as your diagnosis , procedures and supplies used.

We will use your health information for regular health operations. For example: Members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide.

Other Uses or Disclosures

Business Associates: There are some services provided in our organization through contacts with business associates. Examples include physician services in the Emergency Department and Radiology, certain laboratory tests, and a copy service we use when making copies of your health record. When these services are contracted, we may disclose your health infonnation to our business associate so that they can perform the job we've asked them to do and bill you or your third party payer for services rendered . So that your health infonnation is protected, however, we require the business associate to appropriately safeguard your information.

, Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location , and general condition.

Communication with Family: Health professionals, using their best judgment, may disclose to a family member, other relative, close personal friefld or any other person you identify, health infonnation relevant to that person's involvement in your care or payment related to your care.

Research: We may disclose information to researchers when their research has been approved by an Institutional Review Board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.

Marketing: We may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits and ;services that may be of interest to you.

Public Health : As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability.

Correctiona~ Institution: Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof, health information necessary for your health, and the health and safety of other individuals.

Law Enforcement: We may disclose health information for law enforcement purposes as required by law, or in response to a valid subpoena.

Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attomey, provided that a workforce member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.