Podiatry Intake Form | Podiatrist, Foot Doctor Millburn, NJ 07041 and Florham Park, NJ 07932

Please complete all required fields!

Please complete the following form and answer all questions before arriving for your appointment.

Be sure to include your insurance information.
We'll see you soon!

Have you had your vaccine? (*)

COVID-19 Influenza Pneumonia (If over age 65) None

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Patient Information

First name (*)

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Middle Initial

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Last name (*)

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Your Email Address (Responsible Party) (*)

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Mailing Address (*)

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City (*)

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State (*)

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Zip-Code (*)

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Phone number (Cell, Home, Work) (*)

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Phone Type(*)

Cell Home Work

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Date of Birth: Month (*)

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Day (*)

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Year (*)

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Sex (*)

Male Female

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Marital Status (*)

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Height (*)

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Weight (*)

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Shoe size (*)

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Race(*)

*This information is requested due to Healthcare Reform laws dictated by Congress.

Ethnicity

Hispanic or Latino Non-Hispanic or Non-Latino Decline to Specify Invalid Input

Preferred Language(*)

English Spanish Other

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Specify

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Are you pregnant?(*)

No Yes Invalid Input

Are you nursing?(*)

No Yes Invalid Input

Primary Care Physician (*)

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Primary Care Physician Address (*)

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Physician Phone Number (*)

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Date last seen: Month

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Day

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Year

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Pharmacy (*)

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Pharmacy Phone (*)

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Who?

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Other

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Primary Reason for Visit (*)

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Duration of Condition (*)

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Please list any drug/food allergies (*)

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List Medications and Dosage You Take (*)

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Specify other

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Please list past surgeries and year surgery was performed (*)

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

No Yes

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Do you drink alcohol?(*)

Never Past Yes

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How often?

Daily 1-2 x Week 1-2 x Month 1-2 x Year Invalid Input

Do you smoke, vape, use chewing tobacco or marijuana?(*)

Never Past Yes

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How many per day?

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Method of Quitting

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

Never Past Yes

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Please specify

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Family History

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

Diabetes

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Stroke

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Cancer

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Arthritis

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Heart Attack

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Hypertension/High Blood Pressure

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Insurance Information

Subscriber's Name (*)

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Subscriber's D.O.B. (*)

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Patient's Relation to the Subscriber (*)

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HMO (*)

Yes No

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Primary Insurance (*)

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Policy Number (*)

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Policy Holder Name (*)

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Policy Holder Date of Birth: Month (*)

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Day (*)

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Year (*)

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Secondary Insurance

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Secondary Policy Number

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Occupation (*)

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Employer (*)

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Employer Address

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City

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State

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Zip-Code

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Employer Phone Number

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Emergency Contact

First Name (*)

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Last Name (*)

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Relationship to Patient (*)

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Phone (*)

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Responsible Party (if minor patient)

First Name

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Last Name

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Relationship to Patient

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Date of Birth: Month

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Day

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Year

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Authorization for Release of Information to Family Members

First Name: (*)

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Middle Initial:

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Last Name: (*)

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Date of Birth: Month (*)

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Day: (*)

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Year: (*)

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Many of our patients allow family members such as their spouse, parents or others to call and request medical or billing information. Under the requirements of HIPAA, we are not allowed to give this information to anyone without the patient's consent. If you wish to have your medical or billing information released to family members you must sign this form. Signing this form will only give information to family members indicated below.

I authorize The Podiatry Center, PC to release my medical and/or billing information to the following individual (s):

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Relation to Patient:

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Relation to Patient:

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Relation to Patient:

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Patient Information

I understand I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclosed.

I understand that information disclosed to any above recipient is no longer protected by federal or state law and may be subject to redisclosure by the above recipient.

You have the right to revoke this consent in writing.

Please sign with your initials (*)

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Financial Policy

All co-payments are due at the time of visit. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered a violation of the contract you have with your insurance company. Our office accepts cash, checks (post-dated checks are not accepted), credit and debit cards.
Co-insurance and unmet deductibles are due prior to scheduled surgeries and procedures. Once benefits are verified and your financial responsibility calculated, you will be notified of the payment amount and due date.
You are ultimately responsible for payment of charges for services you receive from our office.
In accordance with your insurance member handbook, it is your responsibility to provide accurate insurance information and to present your insurance ID card at the time of your visit. If you do not have insurance or do not present a valid insurance card, you will be responsible for payment at the time of service. We will provide you with a copy of our billing form so that you can obtain reimbursement from your insurance company.
It is your responsibility to ensure that our physicians are in your insurance network.
If your plan requires a referral, it is your responsibility to obtain this prior to being seen by our providers.
Payment is due for rendered services 10 days from receipt of your billing statement. Outstanding balances must be paid in full prior to any additional visit unless arrangements have been made with our billing department.
There is a service fee of $35 for each time a check is returned. The bank may return your check up to three times before considering it nonnegotiable. Your insurance company does not cover this fee.
A scheduled appointment means that time has been reserved for you. Cancellations for appointments must be received at least 24 hours prior to the scheduled appointment. Cancelations for scheduled surgery must be received at least 5 days prior to the scheduled surgery date and time.
Patients who fail to keep or fail to cancel a scheduled appointment within 24 hours may be charged a $25.00 No Show Fee.
Medical records requests must be received in writing at least 72 hours prior to the date needed. Fees for medical records are set in accordance with allowable amounts as defined by the New Jersey Administrative Code. Fees must be received prior to record delivery.
Administrative Services: There is a $20.00 charge for each required Administrative Service, payable prior to service completion. This Administrative Service Fee covers specific administrative services such as forms completion for family medical leave and disability, letters for insurance authorizations for brand or non-formulary drugs, letters for employers, school, health clubs, and any other administrative items not covered by insurance.
In the event your insurance company should happen to send payment to you (the patient), you agree to forward said payment to our office to be applied to your account.
SELF-PAY: Payment in full is due at the time of service if you do not have health insurance coverage.

Please sign with your initials (*)

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Acknowledgement of Receipt of Notice of Privacy Practice

First Name: (*)

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Middle Initial

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Last Name (*)

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Birth Month (*)

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Birth Day (*)

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Birth Year (*)

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I have been given a copy of The Podiatry Center, PC Notice of Privacy Practices ("Notice") which describes how my health information is used and shared. I Understand that the Practice has the right to change this Notice at any time. I may obtain a current copy by contacting the Practice Privacy Officer.
My signature bellow acknowledges that i have been provided with a copy of Notice of Privacy Practices:

Please sign with your initials

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For Facility Use Only: Complete this section if you are unable to obtain a signature.
If the patient or personnel representative is unable or unwilling to sign this Acknowledgement, or the Acknowledgement is not signed for any other reason, please state the reason:

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Please ensure you have completed all mandatory fields on this form (indicated with an (*) asterisk next to the field) and please wait until our thank you page loads to ensure the form was successfully submitted otherwise your data will be lost.

Patient Information

Social History

Family History

Insurance Information

Emergency Contact

Responsible Party (if minor patient)

Authorization for Release of Information to Family Members

Patient Information

Financial Policy

Acknowledgement of Receipt of Notice of Privacy Practice

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