FDFAC New Patient Registration
   

Financial District Foot & Ankle Center pre-register all new patients prior to setting up initial appointments in order to make sure our staff is ready to receive each patient at their reserved time. After we receive your information, we verify your insurance policy and then call you to set up an appointment. This process is usually done within the same day, Monday - Thursday, during normal working hours.
Required Fields are indicated with (*)

There are serious errors in your form submission, please see below for details.

PATIENT INFORMATION    
     
Name*   Birth Date*
 

There are a few issues with your form submission. Please see details above.

    
Home Address*    
     
Phone*   Which number is the best to reach you?*
 
     
Relationship Status*   Email Address*
 
     
Employer*   Occupation
 
     
Employer Address    
     
Spouse/DP Name   Day Time Phone Number
 
     
Emergency Contact*   Day Time Phone Number*
 
     
Primary Care Physician   Phone Number
 
     
Physician Address    
     
How did you come to choose FDFAC?   Is there anyone we can thank for referring you?
 
     
INSURANCE INFORMATION    
     
Name*   Birth Date*
 
     
Social Security Number*   Are you the primary policy holder?*
 
     
If you're not the primary policy holder, please provide the following information
     
Name   Birth Date
 
     
Employer of the primary policy holder   Insurance Company*
 
     
Policy ID Number*   Policy Group Number*
 
     
Plan Code*   Effective Date*
 
     
Do you have additional Health Insurance?*   Secondary Insurer
 
     

Is your visit related to an accident or injury?*

  If yes, please select from list
 
     
Date of injury   Place of injury
 
     
How were you injured?    
   
     
As a convenience, Financial District Foot & Ankle Center will bill your insurance company for fees and services.

Information received by your insurance company does not pre-authorize payment. In order to receive benefits, the member must be covered at the time of service. The benefits information received by FDFAC is not all-inclusive. It is limited to some coverage highlights. Other terms and limitations may apply even though such provisions are not indicated by your insurance provider. All claims are subject to medical review, (by your insurance provider), according to the information submitted by the provider of the service and are subject to benefit maximums and other terms of the member's contract. Please refer to your applicable benefit agreements to determine the appropriate payment amounts and any limitations or exclusions.

FDFAC contracts with an outside billing company, (Computer Billing Services), to handle all billing and insurance payment questions.

FDFAC is not a HMO Contractor, a Workers Comp Provider, a participant of Covered California or any equivalent. FDFAC does not have a contractual relationship with the entities mentioned in this paragraph.

Assignment of Benefits: I hereby assign payment directly to Financial District Foot & Ankle Center, the insurance benefits otherwise payable to me. I understand that I am financially responsible for the charges not covered by this authorization. I also authorize a photocopy of this assignment as if it were an original copy. If it becomes necessary for the account to be referred to an attorney for collection or suit, the undersigned shall pay the reasonable attorney’s fee and collection expenses. Further, I understand that coinsurance, unsatisfied deductible amounts, etc. are requested at the time of services unless other financial arrangements are made in advance.
Name*   Date*
 
     
MEDICAL HISTORY    
     
Chief Foot Complaint*   How long has this been a problem?
 
     
Have you seen another provider for this condition?*   If so, when?
 
     
Name of provider   Outcome
 
     
Please check all applicable medical conditions that apply to you:      
Arteriosclerosis   Glaucoma   Muscle Spasms
Arthritis   Gout   Pneumonia
Asthma   Heart Disease   Rheumatic Fever
Anemia   Hemophilia   Sinus Troubles
Bronchitis   Hepatitis   Stroke/Seizures
Cancer   High Blood Pressure   Thyroid Problems
Chronic Cough   HIV/AIDS   Tuberculosis
Diabetes   Joint Pain/Stiffness   Ulcers
Emphysema   Kidney Problems  
Fainting   Liver Disease  
             
Family History:      
Arthritis   Diabetes   Hypertension
Cancer   Heart Disease   Vascular Disease
       
Surgical History:   Date      
1        
2        
3        
4        
               
Current Medications:            
1   2   3
4   5   6
               
Known Allergies to Medication:           Other Allergies
1   2   3
4   5   6
     
Do you smoke or use nicotine products?*   If so, how often or approx milligrams per day?
 
     
Do you drink alcohol?*   If so, how much per day?
 
     
By clicking the check box, you affirm the Medical Information that you've provided is accurate.
     
PRIVACY PRACTICES (HIPAA)    

This page serves to inform you of the privacy practices of Financial District Foot & Ankle Center and its representatives. The privacy of your medical information is important to us. We intend to honor your privacy in every way possible.

By clicking the check box below you will allow us to disclose your personal health information:

  • For treatment of your medical condition
  • For help in attaining the maximum benefits allowed by your insurance company
  • To any 3rd party representatives also working in the treatment of your medical diagnosis
  • By Superior or Federal Court Subpoena

We respect your rights in maintaining the utmost in privacy in regards to your individual health information. We will not release any of your health information to non-medical entities without your prior written permission.

Financial District Foot & Ankle Center maintains physical and electronic safeguards that restrict unauthorized access to your health information. Such safeguards include secured office facilities, locked file cabinets and controlled computer network systems and password accounts.

We will only disclose your medical information to your health plan or other health care professionals or facilities for purposes of diagnosis or treatment of your medical condition. If you prefer that we do not disclose any or all of your medical condition(s), please inform us so that we may take any necessary precautions.

NOTICE TO CONSUMERS
Doctors of Podiatric Medicine are licensed and regulated by the Medical Board of California.
(800) 633-2322
bpm.ca.gov

I have read FDFAC Privacy Practices, understand this policy and agree to policy intent.*
     
NO SHOW/RESCHEDULING POLICY    
     
Late Cancellation/Reschedule Fee (Within Two Business Days of Appointment, Monday - Thursday):

We understand that unplanned issues come up, and that sometimes you will need to cancel and/or reschedule appointments. However, if you are unable to keep an appointment, we ask that you call our office at least 2 business days in advance -- so that your appointment time can be made available to other patients who require care.

Individuals who cancel or reschedule an appointment with less than two business days notice (or who fail to show up for a scheduled exam) will incur a fee equal to the fee of the appointment being canceled or rescheduled. Similarly, individuals who arrive so late that an examination cannot begin without disturbing another patient's regularly scheduled appointment will also be charged a cancellation/reschedule fee.

Repeated late cancellations or no-show appointments will require non-refundable deposit, and may result in your being referred to another medical practice for services.

I have read FDFAC NO SHOW POLICY, understand it and agree to the terms.*
Name*   Today's Date*
 
     
     

 

 

   
         
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