RIGZ01 Self Pay Patient Packet for Patients without Insurance

Jennifer C. Swan - Right Step Foot Care

Patient Name *

First Name

Middle Name

Last Name

Date of Birth *

Date

Social Security Number

Email *

example@example.com

Mailing Address *

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Cell Phone Number *

Please enter a valid phone number.

Please attach a photo of the patient’s government issued ID (driver’s license, passport or military ID, etc.). Please ensure that these IDs are valid and not expired. You can use your cell phone to take the picture.

📎

Select Image of Government Issued ID

or drag and drop files here

Allowed: jpg, jpeg, png, gif (max 5 MB)

Marital Status

Sex

Height *

Weight *

Shoe Size *

Race

Ethnicity

Preferred Language *

English

Spanish

Other

Do you need an Interpreter?

Yes

No

Have you completed an Advance Directive (living will)?

Yes

No

Do you have a Primary Care Physician? *

Yes

No

Primary Care Physician

Primary Care Physician Address *

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Primary Care Physician Phone Number *

Please enter a valid phone number.

Date Last Seen *

Pharmacy *

Pharmacy Phone Number *

Please enter a valid phone number.

Who referred you to our office? *

Google/Internet

Friend/Family

Doctor Referral

Insurance Website

Facebook

Other

Name of Friend/Family that referred you to our office

Name of Doctor that referred you to our office

Is your problem related to a Workman's Comp injury or an auto/other accident? *

Yes

No

We do not accept Workman's Comp.

Primary Reason for Visit *

Duration of Condition *

What have you done that makes it better? *

What makes it worse? *

Is it limiting your desire activity level? *

Yes

No

Secondary concerns (if there are any)

Do you have any drug allergies? *

Yes

No

Please list any drug allergies and your reactions to them. If NONE, please type none in first line. (REQUIRED)

	Medication	Reaction
1.
2.
3.
4.
5.
6.
7.
8.

Do you take medications or supplements? *

Yes

No

Please list Medications or Supplements you take. If NONE, please type none in the first line. (REQUIRED)

	Medication	Dose	Frequency	Reason
1.
2.
3.
4.
5.
6.
7.
8.

Medical History

Any hospitalizations or major illnesses in last 6 months?

Yes

No

If yes, please explain

Medical History - Please check all that apply

	Check all that apply	*Details
NONE OF THESE
Alzheimer's
Anemia
Arthritis-Rheumatoid
Arthritis-Osteoarthritis
Asthma
Back/neck pain
Bleeding disorders
Chest Pain
Chronic skin infections
Clotting disorders
Congestive heart failure
COPD
Crohn's disease
Diabetes 1
Diabetes 2 (insulin dependent)
Diabetes 2 (non-insulin dependent)
Emphysema
Epilepsy
Fibromyalgia
Gout
Headaches
Hearing disorder
Heart Attack
Heart disease
Hepatitis
Hepatitis B
Hepatitis C
High Blood Pressure
History of DVT/blood clotting
HIV
Hypertension
Kidney disease
*Kidney failure - State what Stage in the Details Column
Liver Disease
Lung Disease
Lyme's disease
Multiple Sclerosis
*Neuropathy-Please state who is managing your Neuropathy in the Details column
Osteoporosis/Penia
Pacemaker
Palpitations/Arrhythmia
Parkinson's Disease
Phlebitis
Poor circulation
Psychiatric disorder - Anxiety
Psychiatric disorder - Depression
Recurrent kidney infections
Recurrent urinary tract infection
Reflux/heartburn
Sciatica
Seizure disorder
Shortness of breath
Stomach ulcer
*Stroke/TIA-list most recent date of Stroke in Details column
Thyroid problem
Ulcerative colitis
Vascular disease
Weight loss/gain
*Other-please state in Details column

Do you have a history of Cancer? *

Yes

No

If yes, what type: (REQUIRED)

Skin: Melanoma

Skin: BCC

Skin: SCC

Other-Specify

Have you had any surgeries or procedures? *

Yes

No

Please list past surgeries or procedures and year surgery or procedure was performed? If NONE, please type NONE in first column. (REQUIRED)

	Surgery or Procedure	Year
1.
2.
3.
4.
5.
6.
7.
8.

Social History

Any falls in the last 3 months?

Yes

No

If yes, please explain

Does the patient use an assistive devise?

Do you drink alcohol? *

Never

Yes

Past

How often

Type of alcohol

Beer

Wine

Liquor

Date quit

Do you smoke, vape or use chewing tobacco? *

Never

Yes

Past

Please specify

How many per day?

Method of Quitting

What year did you quit?

Do you have/have had a substance abuse problem? *

Never

Yes

Past

Please specify

Family History

Which family members had the below medical conditions? (father, mother, sibling, etc.)

	Check all that apply	Family Member	Details
Diabetes
Stroke
Cancer-list type in Details Column
Arthritis
Heart Attack
Hypertension/High Blood Pressure
Other-list in Details Column

Review of Systems

Please checkif you currently have any of these symptoms.

Cardiovascular

Other Cardiovascular Problems not listed above

Genitourinary

Check all that apply

NONE

Blood in urine

Hesitancy

Incontinence

Decreased Frequency

Excessive Urination

Kidney Disease

Kidney Stone

Other Genitourinary Problems not listed above

Gastrointestinal

Other Gastrointestinal Problems not listed above

Hematologic

Check all that apply

NONE

Lower Leg Ulcer

Sickle Cell Disease

Anemia

Blood Thinners

Clotting Disorders

Other Hematologic Problems not listed above

Neurological

Check all that apply

NONE

Tingling

Weakness

Seizures

Numbness

Headaches

Tremors

Paralysis

Other Neurological Problems not listed above

Musculoskeletal

Other Musculoskeletal Problems not listed above

Respiratory

Check all that apply

NONE

Chest Pain

Wheezing

COPD

Coughing

Shortness of Breath

Emphysema

Other Respiratory Problems not listed above

Skin

Check all that apply

NONE

Athletes Foot

Nail Abnormalities

Keloids

Itchiness

Dry, Scaly Skin

Other Skin Problems not listed Above

Responsible Party

The Responsible Party is

the same as the patient

someone other than the patient-see below

Responsible Party Name

First Name

Last Name

Relationship to Patient

Responsible Party Date of Birth

Date

Responsible Party Cell Phone Number

Please enter a valid phone number.

Are you currently employed? *

Yes

No

Employer (REQUIRED)

Employer Address (REQUIRED)

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Employer Phone Number (REQUIRED)

Please enter a valid phone number.

Emergency Contact

Emergency Contact Name

First Name

Last Name

Relationship to Patient

Emergency Contact Phone Number

Please enter a valid phone number.

Digital Signature Authorization: *

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature *

Health Insurance Portability and Accountability Act (HIPAA)
Policies and Procedures

The HIPAA privacy Rules give individuals the right to request restrictions on uses and disclosures of their Protected Health Information (PHI). The individuals is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual's place of work instead of the individual's home. Please check all that apply:

Home or Cell Phone

Leave message with appointment date and time

Leave message with test results

Don't leave messages

Work Phone

Leave message with appointment date and time

Leave message with test results

Don't leave messages

Written Communication

Mail to my home address

Mail to my work address

Home Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Work Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

The Privacy Rule generally requires healthcare providers to take reasonable steps to limit the use and disclosure of, and the request for PHI to the minimum necessary to accomplish the intended purpose. These provisions do not apply to uses of disclosures made pursuant to an authorization request by the individual. Healthcare entities must keep records of PHI disclosures. Information provided below, if completed properly, will constitute an adequate record.

Note: Uses and disclosures for reasons other than treatment, payment, or operations may be permitted without prior consent in case of an emergency.

The following names listed are those to which I give authorization and consent to receive health information regarding appointments, test results and billing:

	Name	Relationship
1.
2.
3.
4.

This authorization shall be in force and effect until written notification from patient.

My signature acknowledges that I have been provided a copy of the Notice of Privacy Practices and I am aware that I may request a copy of this Notice of Privacy at any time.

Digital SignatureAuthorization: *

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature *

Acknowledgement of HIPPA Policy

Please click to View Privacy Policy

I acknowledge that I was provided a copy of the NOTICE OF PRIVACY PRACTICES FOR RIGHT STEP FOOT CARE and have read (or had the opportunity to read if I so choose) and understood the NOTICE. Initials *

Financial Policy

Your insurance policy is a contract that exists between you and your insurance company. Our relationship is with you, the patient, and not the insurance company. If you have questions about your policy, please call the phone number provided on the back of your insurance card. The patient or responsible party is responsible for their bill being paid in full. Upon your initial visit you will be asked to provide a photo ID. Please inform us at every visit of any changes to your insurance coverage and provide us with your most recent insurance card. If RSFC is not notified of these changes, you may be held responsible for services rendered.

Please initial each line indicating your understanding of our policies:

I instruct my health care benefits plan administrator, i.e. PLAN to pay RSFC directly for all professional and medical services provided by RSFC through the means of electronic funds transfer(s)(EFT) or by check(s) made payable to and mailed to RSFC. I AUTHORIZE THE RELEASE OF ANY MEDICALINFORMATION NECESSARY TO PROCESS CLAIMS. Initials *

COPAYMENTS: It is a requirement of your insurance company and required by law that we collect your co-pay. Payment is required before meeting with the doctor. Initials *

DEDUCTIBLES & CO-INSURANCE: If you have a high deductible plan, we may collect a deposit to apply towards your deductible and co-insurance. Any remaining balance after submission to your insurance company is your responsibility. Initials *

SELF-PAY (for non-covered products and services and for patients without insurance coverage): Full payment is due at time of service. Payment for evaluation and management services at minimum will be required before seeing the doctor. Additional procedures/services may be recommended by the doctor. You will be informed of these charges before proceeding with treatment. Initials *

REFERRAL: If your insurance plan requires a referral from your primary care doctor, this will be required at the time of your visit. Without a referral available, we will need to reschedule your appointment or, if you are seen without a referral, you may be held responsible for charges that your insurance denies. Initials *

NO SHOW (FAILURE TO PRESENT FOR YOUR APPOINTMENT): 24 HOURS-NOTICE is required for cancellation of your appointment and failure to do so will incur a $50 fee. Failure to provide 24 HOURS-NOTICE for a scheduled office procedure will incur a $100 fee. Initials *

SURGERY CANCELLATION: Failure to provide 5 BUSINESS-DAYS' notice before surgery will incur a $500 fee. Initials *

BALANCES/COLLECTION FEES: If payment of an outstanding balance is not received within 30 days from the postmark date of a mailed statement or e-statement (time stamp), a $10 re-billing fee may be added to each additional statement. Our patient portal offers the ability to view statements and submit payment conveniently and securely. Patients with balances more than 90 days overdue will be turned over to collections and a $35 administrative fee will be applied. Initials *

OUT OF NETWORK: In cases when we are not providers for your insurance, your visit will be an Out-of-network service which you will be personally responsible for. Your insurance may impose a deductible and higher copayments than if you received services from a provider in your network. If you do not have Out-of-network benefits, you are personally responsible for the full amount of the charges payable on demand. You are personally responsible for all deductibles and copayments required under your benefit plan and any unpaid charges denied in whole or in part by your insurance. Initials *

FMLA/DISABILITY/MEDICAL RECORDS: There is a $40 charge for having the doctor complete these forms. Requested forms will be completed within 72 hours of diagnosis and care plan. There is a $30 fee to obtain a copy of your medical records. Initials *

I also give permission for photographs of my feet to be taken that are to be kept as part of my medical record only. They will not be published as part of medical research or disbursed in any way without my permission. Initials *

I have read and understand these financial policies and that all provided financial figures serve solely as an estimate and are subject to change based on insurance determination.

Patient Name

First Name

Middle Name

Last Name

Digital SignatureAuthorization: *

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Patient/Responsible Party Signature *

Date *

Date