New Patient Form

PATIENT INFORMATION

Patient First Name

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Patient Last Name

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Date of Birth

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Street Address

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City

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State

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Zipcode

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Home Phone

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Cell

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Guarantor's Social Security #

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Driver's License #

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Marital Status

Married

Single

Widowed

Divorced

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Patient Employed By:

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Occupation

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Company Address

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Zipcode

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Work Phone #

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Sex

Male

Female

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Date of Inquiry

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INSURANCE INFORMATION

Policy Holder's Name

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Relationship to Patient

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Address

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Phone Number

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Social Security #

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Date of Birth

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Primary Insurance

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Group #

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ID #

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Secondary Insurance

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Group #

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ID #

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Medicare #

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Medicaid #

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Referred By

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Phone

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INSURANCE AUTHORIZATION

Medicare Assignment for Covered Services

I certify the information given in applying for payment is correct and request payment of authorized benefits be made on my behalf.

Assignment of Insurance Benefits

I hereby authorize payment to Ed Davis, DPM, FACFAS for medical services. I represent that I have insurance coverage and do hereby authorize Ed Davis, DPM, FACFAS to release and obtain all information necessary to secure payment of said benefits. If my insurance fails to pay Ed Davis, DPM, FACFAS for any reason, I agree to pay all unpaid balances.

I have read and understand medical product disclosure, medicare assignment, and assignment of insurance benefits and agree to all terms stated.

Patient Signature

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Date

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PATIENT HISTORY

Patient Name

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Date of Birth

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Date you are filling out this form

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Who is the physician or provider referring you to us?

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What type of complaint or disease is the reason for requesting this visit?

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Tell Us About Yourself

Home Situation

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How long have you been married, divorced, widowed or in a domestic partnership?

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Do you have kids?

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If yes, are they healthy?

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Employment

Occupation type / type of work / jobs

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MEDICAL HISTORY

Habits

Do you smoke?

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If yes, how many packs per day?

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If you have quit, how long ago?

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Do you use alcohol?

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If yes, how often do you drink?

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If you have quit, how long ago?

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Do friends or family worry about your alcohol intake?

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Medical History

Please list other diseases from which you currently suffer (heart, lung, etc):

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Please list other medical conditions from which you have suffered in the past:

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Please list any surgeries (operations), reason for surgery, and date of surgery:

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Medications

Please list any and all prescription medications you take, the dose and how often they are taken:

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Please list any and all non-prescription medications or herbal preparations you take, the dose and how often they are taken:

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Preferred pharmacy

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Pharmacy Phone

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Please list any drug allergies

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Is there a family history of...

Colon or Rectal Cancer

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If yes, who?

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Other Cancer

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If yes, who?

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Heart Disease

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If yes, who?

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Diabetes

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If yes, who?

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High Blood Pressure

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If yes, who?

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Liver Disease

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If yes, who?

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High Cholesterol

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If yes, who?

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Alcohol or Drug Abuse

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If yes, who?

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Depression or Psychiatric Illness

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If yes, who?

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Genetic (Inherited) Disorder

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If yes, who?

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Other

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What condition and who?

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SYMPTOM REVIEW

General

Poor Sleep

Fever

Headache

Weight Gain / Loss of 10+ lbs During Last 6 Months

Depression

Gastrointestinal

Poor Appetite

Abdominal Pain

Indigestion

Trouble Swallowing

Diarrhea

Constipation

Change in Bowel Habits

Nausea or Vomiting

Rectal Bleeding

History of Liver Disease or Abnormal Liver Tests

Cardiovascular

Chest Pain

History of Angina or Heart Attack

History of High Blood Pressure

History of Irregular Heart Beat

History of Poor Circulation

Pulmonary / Lungs

Shortness of Breath

Persistent Cough

Coughing Up Blood

Asthma or Wheezing

Eyes, Ears, Nose, Throat

Blurred Vision

Other Change in Vision

History of Glaucoma or Cataracts

Loss of Hearing

Ringing in Ears

Sinus Problems

Hoarseness

Muscle, Joint, Bone

Swelling, Pain, Weakness, Numbness in:

Arms or Hands

Back or Hips

Legs or Feet

Neck or Shoulders

Endocrine

History of Diabetes

History of Thyroid Disease

Change in Tolerance to Hot or Cold Weather

Excessive Thirst

Neurologic

History of Stroke

Blackouts or Loss of Consciousness

Genitourinary

Frequent or Painful Urination

Blood in Urine

Skin

Itching

Easy Bruising

Change in Moles

Women Only

Abnormal PAP Smear

Bleeding Between Periods

Date of Last Mammogram

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Men Only

PSA

Anything Else?

Are you experiencing an unusual stressful situation?

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Are there any specific personal issues you would like to bring up at the time of your visit?

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IMMUNIZATIONS

Pneumococcal

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If yes, approximately year given?

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Hepatitis A

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If yes, approximate year given?

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Hepatitis B

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If yes, approximate year given?

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Tetanus

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If yes, approximate year given?

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Have you ever received a blood infusion?

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If yes, when?

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Do you use seatbelts?

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HIPAA PATIENT QUESTIONNAIRE

Please list family member and/or person, if any, whom we may inform about your general medical condition, your diagnosis and any billing questions (including treatment, payment and healthcare operations).

As a reminder, these will be the ONLY people we will be able to speak to or release any information to regarding your account.

Name

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Phone

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Name

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Phone

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Can confidential messages (i.e., appointment reminders) be left on your telephone answering machine or voicemail?

Yes

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Please indicate if we may mail your appointment reminder / lab / x-ray results.

Yes

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This form will remain in effect until you make any changes in writing.

Patient Signature

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Date

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FINANCIAL POLICY

Eddie Davis, DPM, FACFAS

109 Gallery Circle, Suite 119 San Antonio, TX 78258

As insurance coverage decreases and the patient’s financial responsibility increases, we understand the need for clear communication of our financial policies. To better serve the needs of our patients, we have added valuable tools to help you meet your increased medical expenses.

***NOTICE: WE DO NOT FILE TO SECONDARY INSURANCE CARRIERS**

All coinsurance, copay, deductible and out of pocket amounts listed under your insurance carrier are due at the time of service. You may file with your secondary insurance carrier upon receipt of the explanation of payment from your primary insurance carrier.
We will continue to look to insurance companies for their payment and assist you in receiving proper reimbursement for our services. Unfortunately, most insurances no longer cover services fully and most current insurance plans chosen by our patients require significant out-ofpocket expenses to be paid by the patient. Dr. Davis feels that it is important to recommend treatments based on their effectiveness and the best interest of the patient, not based on insurance coverage.
It is your responsibility to verify that all requirements of your insurance plan are met. We will assist you with pre-certification for procedures ordered by our office, but it is ultimately your responsibility to verify whether any care you receive is covered by your insurance. With continuous changes in coverage, it is important for you to verify your benefits and be aware of all restrictions and expenses of your plan.
In accordance with the requirements of most insurance contracts, we will require payment of office co-payments, deductible and non-covered services at the time of service. Certain services may or may not be covered and insurance companies only will make decisions after the service has been performed and submitted for payment, so it is necessary for us to collect a deposit under such circumstances. Insurance companies may take anywhere from 3 to several months to adjudicate claims and, based in Texas Administrative Code, Paragraph 3.70-3C, have up to 180 days after patient care has been completed. Patient refunds for overpayments, should that occur, will be issued by our office at 180 days after completion of patient care.
If we are a contracted provider on your primary insurance plan, we will file a claim with your carrier, and you will be billed after they have responded to our claim. Upon receipt of their response, payment or denial, you will receive a statement for the amount your insurance company notifies us is your responsibility. The State of Texas has a “prompt pay statue”, 28TAC Section 21.2815 which requires health insurance companies to respond to an electronically filed claim within days. Keep in mind that the regulation requires a response, not payment. As providers we have no means to compel insurance companies to follow this regulation but encourage patients to contact their insurance companies and request a response.
If our doctor is not a contracted provider for your insurance plan, we will file a claim with the information you provide and will be billed for the entire amount. You will receive monthly statements and will look to you for payment. You will be responsible for working with your insurance company to insure prompt payment.
If you do not have your insurance card with you, you will be billed for the entire amount and asked for payment at the time of service. It is your responsibility to give us your card at each visit (if required) and inform us of any policy changes that may have occurred. We will not be able to file your insurance without a copy of your insurance card and your social security number. New patients are also required to show a photo id which helps prevent misuse of an insurance card.
If you have an insurance plan that requires a referral, we will require that the referral be here before we can see you. We do our best to assist you in obtaining a referral, but to expedite matters, it is best for you to contact your primary care physician and have them fax the referral to us or bring the referral with you.
Pre-certification for prescription drugs. Our office, as do most physicians’ offices, write several prescriptions per day. We do not write letters to insurance companies/pharmacies nor fill out forms for drug pre-certification for generic drugs.
We require New Patient appointment cancellations and surgery cancellations with our office to be made no less than 48 hours prior to your appointment/surgery time. There will be a $50.00 fee for New patient office visit no shows and late cancellations. There will be a $25.00 fee for established patient office visit no shows and late cancellation. A $100.00 fee will be charged for surgery reschedule/cancellation. A $500.00 fee will be charged for surgery day no show.
Any Durable Medical Equipment is non-returnable/refundable.

Patient Signature

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Date

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