Dr. Sandra M. WeaklandDr. Alissa KuizinasDr. Summer Getzen

Concord Foot and Ankle

Patient Name

Last Name First Name Middle Initial

Address

City

State Zip E-mail

Home Phone ( ) Cell Phone ( ) Best : ❏ Home or ❏ Cell

Emergency Contact:

Relationship: Telephone Number: ( )

PATIENT INFORMATION

Date

Signature of Patient, Parent, Guardian or Personal Representative Date

54 Baker Ave Extension • Suite 301Concord, MA 01742

133 Littleton Road • Suite 204Westford, MA 01886

P | 978-369-5282F | 978-369-2926

www.concordfeet.com

OFFICE POLICIESIf your health insurance plan requires a referral, it is your responsibility to obtain the referral from your primary care physician prior to your visit.Payments and co-payments are due at the time of your visit.We ask that you show consideration to both our staff and other patients waiting for appointments by notifying our office at least 24 hours in advance if you are unable to keep a scheduled appointment.There will be a fee for all no-shows or missed appointments without the above 24 hour notice.

INSURANCE ASSIGNMENT AND RELEASEI certify that I have insurance coverage and assign directly to Concord Foot and Ankle all insurance benefits, if any, otherwise payable to me for services rendered. I authorize the use of my signature on all insurance submissions. Concord Foot and Ankle may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. I request that payment of benefits be made to me or on my behalf to Concord Foot and Ankle for any service furnished to me.

TREATMENT CONSENTI hereby consent and give my permission to the doctor (and the doctor’s assistants or designated replacement) to administer and perform such treatment as the doctor deems necessary.

Birthdate: Sex: ❏ M ❏ F

❏ Married ❏ Widowed ❏ Single ❏ Minor ❏ Separated ❏ Divorced ❏ Partnered for years

Language Ethnicity: ❏ Hispanic ❏ Non-Hispanic

Race: ❏ Asian ❏ Caucasian ❏ Black or African American ❏ Hispanic ❏ Other ❏ Declined

MEDICAL HISTORY

Height: Weight: Recent Blood pressure: Shoe Size:

Place a mark on “Yes” or No” to indicate if you have had any of the following: Describe Below.

Aids/HIV ❏Yes ❏No

Allergies to Anesthetics ❏Yes ❏No

Allergies to Medicine or Drugs ❏Yes ❏No

Anemia ❏Yes ❏No

Angina ❏Yes ❏No

Arthritis ❏Yes ❏No

❏Yes ❏No

Asthma ❏Yes ❏No

Back Problems ❏Yes ❏No

Bleeding Disorders ❏Yes ❏No

Cancer ❏Yes ❏No

Chemical Dependency ❏Yes ❏No

Chest Pain ❏Yes ❏No

Chronic Diarrhea ❏Yes ❏No

Circulatory Problems ❏Yes ❏No

Collagen Vascular Disease i.e. Lupus ❏Yes ❏No

Clotting Disorder ❏Yes ❏No

Diabetes ❏Yes ❏No

DVT or PE ❏Yes ❏No

Ear Problems ❏Yes ❏No

Epilepsy ❏Yes ❏No

Eye Problems ❏Yes ❏No

GERD ❏Yes ❏No

Gout ❏Yes ❏No

Headaches ❏Yes ❏No

Heart Disease ❏Yes ❏No

Hepatitis or Jaundice ❏Yes ❏No

High Blood Pressure ❏Yes ❏No

Kidney Problems ❏Yes ❏No

Liver Disease ❏Yes ❏No

Low Blood Pressure ❏Yes ❏No

Neuropathy ❏Yes ❏No

Phlebitis ❏Yes ❏No

Plantar Fasciitis ❏Yes ❏No

Psychiatric Care ❏Yes ❏No

Radiation Treatment ❏Yes ❏No

Respiratory Disease ❏Yes ❏No

Rheumatic Fever ❏Yes ❏No

Shortness of Breath ❏Yes ❏No

Sinus Problems ❏Yes ❏No

Scars/Keloids ❏Yes ❏No

Stroke ❏Yes ❏No

Thyroid Disease ❏Yes ❏No

Tuberculosis ❏Yes ❏No

Ulcers ❏Yes ❏No

Varicose Veins ❏Yes ❏No

Venereal Disease ❏Yes ❏No

Weight Loss, unexplained ❏Yes ❏No

Describe Above:

List past foot surgeries you have had

Other past surgeries you have had

Primary Care Physician Phone#( )

Address

Pharmacy Name (s) Pharmacy Phone#( )

MEDICATIONS

Include prescriptions, over-the-counter medications, vitamins, and supplements:

ALLERGIES

❏ Adhesive/Tape ❏ Local Anesthetics

❏ Anticoagulant Therapy ❏ Novocaine

❏ Aspirin ❏ Penicillin

Seafood/Shellfish❏ Codeine ❏

❏ Demerol ❏ Sulfa

❏ Iodine/Contrast Dye ❏ Other

❏ None

What was your chief complaint for which you came to be treated?

Please Describe

FAMILY PODIATRY HISTORY Mother

Father Siblings

PODIATRIC HISTORY

Your Occupation:

Cigarette/Tobacco use

Alcohol use

Illicit Drug Use

Activities/Sports

Patient Name: D.O.B.

DR. SANDRAWEAKLANDDR. SUMMER GETZENDR. ALISSA KUIZINAS

CONSENT TO DISCLOSE HEALTH INFORMATION FOR TREATMENT, PAYMENT, & HEALTH CARE OPERATIONS

Patient Name: __________________________________________________________________

Address: ______________________________________________________________________

Telephone: ________________________ Date of Birth: ________________________

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES: By my signature below, I herebyacknowledge that I have received/declined a copy of this office’s NOTICE OF PRIVACY PRACTICES.

CONSENT TO DISCLOSE MY GENERAL HEALTH INFORMATION: By my signature below, I hereby authorize this office todisclose my health information so that I may be treated, seek payment from third parties for said treatment, and tocarry out health care operations (e.g. quality assurance). I further authorize this office to disclose my health informationto insurers and providers outside of this office as necessary so that these providers may treat, seek payment for saidtreatment, and for the purpose of health care operations.

I further authorize that this office may disclose my medical information on my home answering machine/voice mail andto the following family members:

_______________________________________________________________________________________________

________________________________________________________________________________________________(Name and relationship of family members)

CONSENT TO DISCLOSE MY HIGHLY CONFIDENTIAL HEALTH INFORMATION:

I understand that my medical record currently contains, or may in the future contain, confidential information.By my signature below, I hereby authorize this office to disclose of this information as part of my medicalrecord to insurers and providers outside of this office for the purpose of treatment, payment for saidtreatment, and for the purpose of health care operations.

__________________________________________ _________________

Signature of Patient, Parent, Guardian or Personal Representative Date

Concord Foot and Ankle Center

Financial Policies Consent to Treat Assignment of Benefits Privacy Notice

________________________________________________________

Welcome and thank you for choosing our office for your medical care. We are committed to caring for

you with quality and compassion. The medical services that you consent to receive have a financial

responsibility on your part. This document is to inform you of your personal responsibilities in regards

to your insurance, referrals, and payments to this office.

INSURANCE: We participate in most insurance plans. However, there are a few that we do not. It is your responsibility to know and understand your insurance policies, benefits, and participating providers. If you are insured by a plan that we participate in but do not have an up-to-date insurance card and photo ID, payment in full for each visit is required at the time of the visit.

MEDICARE: We are a participating Medicare provider. We accept Medicare benefit amounts. Medicare and your secondary insurance will be billed for you. However, not all services are covered by Medicare. All Medicare patients have a yearly deductible and will have to pay their deductible until it has been met. If your secondary insurance does not pay in a 3 month period after Medicare has paid, you will be responsible for the 20% copay amount. We are not responsible for continually billing the secondary insurance.

SELF PAY: Payment in full is due at the time of service if you do not have health insurance.

NON-COVERED SERVICES: Please be aware that not all podiatry services are covered by all insurance plans. You will be responsible for full payment of these services at the time of the visit. If your insurance company is billed and denies coverage, you are responsible for these services.

REFERRALS/AUTHORIZATIONS: We are required by contract to follow the guidelines of your managed insurance plans. These plans mandate that you, the patient, must have a referral from your primary care physician prior to or at the time of the visit. The patient is responsible for contacting and obtaining that referral prior to any services are rendered. Primary care offices often do not “back date” referrals. Therefore, you are financially responsible for all services rendered without a referral, unless a referral is presented prior to or at the time of the visit. You have the option to reschedule your appointment with a 24 hour notice until the referral is obtained.

CLAIM SUBMISSION: We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to provide certain information directly to them. It is your responsibility to comply with their requests. Please be aware that the balance of your claim for services provided by this office, is your responsibility whether or not your insurance company pays the claim. Your insurance benefit is a contract between you and your insurance company.

PATIENT BILLING: ALL COPAYMENTS, CO-INSURANCE, BALANCES AND DEDUCTIBLES MUST BE PAID AT THE TIME OF THE SERVICE. This arrangement is part of your contract with your insurance company. Failure on our part to collect copayments and deductibles is considered fraud. Please help us to uphold the obligations set forth by your insurance company by paying your portion of the benefits at each visit. As a courtesy, our office does verify benefits with your insurance carrier. However, it is your responsibility to know your own benefits as to what is covered and what is not.

DURABLE MEDICAL PRODUCTS: If a patient is unsatisfied with a non-custom product, it must be returned unused within 30 days per insurance guidelines. Returns after 30 days will not be permitted or refunded for any reason. Any custom device is not returnable for any reason.

RECORDS FEE: We will provide copies of your records at no charge. We will provide a copy of your x-rays for a charge of $5.

CANCELLED OR MISSED APPOINTMENTS: If you cannot keep an appointment time, we require 24hours notice or there may be a fee of $25.00. If you miss an appointment without notice, there may be a $25.00 fee. If you miss 3 or more appointments, you may be required to pay a $50.00 deposit to hold an appointment time slot or may be terminated from the practice. If you arrive late for an appointment, we may need to reschedule you at a later date. You will bear full financial responsibility for any fees occurred.

COLLECTIONS FEE: You will be sent 3 notices for your overdue balances. After the third notice, your account may be forwarded to a collection agency or taken to small claims court. If either of these occur, a 35% fee will be added to your account and you will bear complete financial responsibility for any fees incurred in the process.

Payment arrangements can be made on a case by case basis. We accept cash, credit cards, care credit and checks. A returned check will incur a fee of $25.00.

PRIVACY STATEMENT: Any information disclosed in your records will remain confidential and will not be used for any other reason except in providing quality care and treatment as well as to submit your claim to your insurance company and contact you as needed.

ASSIGNMENT OF BENEFITS: I certify that I have insurance coverage and assign Dr. Sandra M. Weakland, DPM, PC all insurance benefits for services rendered. I understand that I am responsible for payment of deductibles, co-payments, co-insurance, non-covered services, and any other fees at the time of service. I hereby authorize the doctor to release all information necessary to secure payment of benefits. I authorize Release of Medical Information to my insurance carrier, or requested physician, to provide continuity of care. I authorize the use of this signature on all insurance submissions.

CONSENT TO TREAT: I hereby consent and give permission to the doctor and the doctor’s assistants or designated replacement: to administer and perform such treatment as the doctor deems necessary.

SIGNATURE:

Signature of patient, parent, guardian or personal representative Date