medical history/ health questionnaire do you have …yes or no if yes, please list name &...

Patient Name:_____________________ DOB:________________ Today’s Date:_________

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MEDICAL HISTORY/ HEALTH QUESTIONNAIRE:

Date of Last Medical Exam_____________ Name of Medical Doctor______________________

1.) Do You Have Family Physician or a Private Physician? Yes or No If Yes, Please List Name & Address:_______________________________________________

2.) Have You Been Hospitalized In the Last 2 Years? Yes or No If Yes, Reason________________________________________________________________

3.) Do You Have Any Allergies To Any Drugs or Foods? Yes or No If Yes, Reason________________________________________________________________

4.) Are You Taking Any Medications/Supplements? Yes or No (**If Yes, Please List On Attached Sheet**)

5.) Do You Or Have You Ever Had Any Of The Following: (Circle Yes Or No)

HIV/AIDS: Yes / No Anemia: Yes / No Arthritis: Yes / No Asthma/Hay Fever: Yes / No

Diabetes: Yes / No Gout: Yes / No Hepatitis: Yes / No High Blood Pressure: Yes / No

Rheumatic Fever: Yes / No Emphysema: Yes / No Tuberculosis: Yes / No

Stroke: Yes / No Seizures: Yes / No Blood Clots: Yes / No COPD: Yes / No

Recurrent Infections: Yes / No Tumor/Growth: Yes / No Heart Problems: Yes / No

Heart Murmur: Yes / No Abnormal Bleeding: Yes / No

Women: Are You Pregnant or Think You May Be Pregnant? Yes / No

6.) Have You Had Any Previous Surgery? Yes or No If Yes, Please List All Surgeries:___________________________________________________

7.) Have You Had Any Problems With Anesthesia? Yes or No

CONT. MEDICAL HISTORY/ HEALTH QUESTIONNAIRE:

8.) Have You Had Any Problems With Abnormally Easy Bleeding? Yes or No

Page ! of 3 204/2017 KAH

Patient Name:_____________________ DOB:________________ Today’s Date:_________

9.) Have You Had Any Major Trauma (Fractures, Etc.)? Yes or No

10.) Do You Have Any Known Contagious Diseases? Yes or No

11.) Do You Smoke? Yes or No If Yes, How Many Packs Per Day?_________________ Number Of Years_________________

12.) Do You Drink Alcohol? Yes or No If Yes, Which Type: Beer Wine Hard Liquor How Much Per Week________________

*MEDICATION LIST*

Prescription:______________________ Dosage:_____________ Times Per Day:___________










Please Provide Other Health Information You Deem Important: ______________________ ________________________________________________________________________________________________________________________________________________________

Patient/Legal Guardian Signature:_________________________________ Date:___________

Page ! of 3 304/2017 KAH

ASSIGNMENT OF BENEFITS, DIRECTION TO PAY, RELEASE OF INFORMATION, AND LIFE TIME MEDICARE PART B SIGNATURE

AUTHORIZATION. ASSIGNMENT BENEFITS:

The undersigned patient assigns the benefits of insurance and any over due interest payments under the no-fault Policy of Automobile Insurance, also known as Personal Injury Protection (P.I.P.), or Medical Payments policy of insurance with my insurance carrier or the responsible insurer to “Toes On The Go” for services rendered. The medical provider agrees to accept the irrevocable assignment of benefits for services rendered to the patient. This assignment applies to both past and future medical expenses. A photocopy of this assignment is to be considered as valid as an original. The undersigned patient agrees to pay any applicable deductible, co-payments, or for any and all other services not covered by the insurance policy. DIRECTION TO PAY: The undersigned patient further directs the insurer to pay “Toes On The Go” directly for the services rendered. RELEASE OF INFORMATION: I hereby authorize “Toes On The Go” to furnish my insurance company or companies, or their representatives with any and all information necessary to obtain claim payment that may be contained in my medical records. __________________________________________DATE:________________ (Patient’s signature or parent’s signature if patient is a minor) LIFETIME MEDICARE PART B SIGNATURE AUTHORIZATION: I authorize any holder of medical or other information about me to release to the Social Security Administration or it’s intermediaries or carriers or the billing agent of “Toes On The Go” any information needed for this or a related Medicare Claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits be made to the holder of this assignment on my behalf. I understand that I am responsible for any health deductibles and coinsurance. _______________________________________________________________ Signature Date: ___________ Medicare#________________ (Medicare signature only) IF PATIENT IS UNDER 18: I hereby give my permission for _______________________to be treated by Dr. Michele Kraft. ____________________________________ ________________ (Signature/Telephone Verification) Date ____________________________________ ________________ Witness Date

TOES ON THE GO FINANCIAL POLICY

Thank you for choosing Dr. Michele Kraft as your health care podiatrist. We are committed to delivering quality, affordable foot care with a “gentle” approach. Please understand that payment of your bill is part of your treatment. Your clear understanding of our financial policy is important to our professional relationship. All patients must thoroughly complete our Patient Registration form and please ask us if you need assistance. We accept cash, personal checks, Visa, MasterCard, and check debit cards. We have a $25 charge for returned checks. PAYMENT FOR SERVICE Payment is due when services are rendered, unless you have Medicare/Private insurance and you are receiving a covered service under your insurance guidelines. For Medicare, most routine foot care is not covered by Medicare, unless you have a qualifying medical diagnosis and associated vascular or neurological changes to your feet. There are no refunds or exchanges on services rendered or supplies dispensed through this office. REGARDING INSURANCE Insurance is a contract BETWEEN YOU AND YOUR INSURANCE COMPANY. At this time, we are contracted with Medicare and some private insurance carriers. Reimbursement is subject to the terms of your contract with your carrier. However, we will assist you in billing and require $50.00 initial payment to submit billing electronically if we are not contracted with your insurance co. If we are contracted with your insurance, you are responsible for your co-pay and unmet deductible at the time of service. Once your insurance company has paid on a claim, you are responsible for any outstanding balances, once contracted adjustments have been made. When we send you a statement, we expect payment in full within 30 days. Late payments will accrue a finance charge of 12%/month on outstanding balances. WE DO NOT ACCEPT MEDI-CAL INSURANCE MISSED OR LATE APPOINTMENTS It is our policy to charge $50 for missed appointments if not cancelled at least 24 hours in advance. The only exception is a situation that is out of your control, i.e., sickness or family emergency. If you are 15 minutes late arriving to your scheduled appointment, there is a strong possibility that you will need to reschedule. **Please help us serve you better by keeping your appointments. Thank you ________________________________________ _________________ Signature Date

Michele M. Kraft, DPM “Toes on the Go”

Consent for Treatment I hereby grant complete authority to Michele M. Kraft, DPM, to administer any treatment and administer such x-rays, anesthetics and to perform such podiatric procedures as may be deemed necessary or advisable in the diagnosis and treatment of my podiatric condition. Please understand your bill is your own personal full responsibility. Insurance is a contract between the policy holder and the company. In the event your insurance company is slow to pay or for some reason disallows the claim, payment of the account is your responsibility. We cannot be responsible for misinformation given to us or unapproved charges from the insurance company or any lab facility. Signature __________________________________________ Date __________________________________________ Relationship to patient __________________________________________ “Making Feet Happy One Step at a Time”

medical history/ health questionnaire do you have …yes or no if yes, please list name &...

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