PATIENT INFORMATION
Emergency Contact Information
Primary Care Doctor
Referral Information
Pharmacy Information
Medication List
Please list all medications you are currently taking or provide a copy of your medication list.
Social History
Employment Information
Patient Medical History
Family Medical History
If applies, Indicate which immediate family member (mother, father, brother and/or sister).
Surgery History
Please list al prior surgeries
Vital Signs
High blood pressure & pulse will be taken by medical assistant.
Current Problem (Chief Complaint)
Chief Complaint Details
*** Diabetic Patients Only ***
Financial Policy for Kaplansky Foot & Ankle Centers
Kaplansky Foot and Ankle Centers would like to thank you for choosing our office to provide you with medical care. We are committed to serving you with skill and high quality care. The medical services provided by our office are services you have elected to receive which may imply a financial responsibility on your part.
No Shows: There may be a charge of $30.00 for all no-show appointments.
Insurance: All co-payments and deductibles must be paid at the time of service. We participate in most insurance plans. If you are not insured by a plan we participate with, payment in full is expected at each visit. If you are insured by a plan we participate with but do not have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility.
Medicare: We are a participating Medicare provider; however, that does not mean that all services are covered. Patients are responsible for their annual deductible if not yet met, and for any co-payments, usually 20% of the allowed amount.
Self-Pay: Payment in full is due at the time of service if you do not have health insurance.
Non-Covered Services: Some services may not be covered or considered reasonable or necessary by Medicare or other insurers. You are responsible for payment of these services.
Referrals/Authorizations: We are required to follow your managed care plan's guidelines, which mandate a referral from your primary care physician prior to seeking specialty care. You are financially responsible for services received unless a referral is presented at the time of the visit.
Claim Submission: We will submit your claims and assist you in getting them paid. The balance of your claim is your responsibility whether or not your insurance company pays. Your insurance benefit is a contract between you and your insurance company.
Patient Billing: You will be sent up to three notices for your financial responsibility. After the third notice, your account may be forwarded to collections. We accept Cash, Check, or VISA/MasterCard. A $25.00 fee applies to returned checks.
I have read the above policy regarding my financial responsibility and agree to pay Kaplansky Foot & Ankle Centers any balance unpaid by my insurance carrier for myself or the below named person.
Insurance Information
Insurance Information
I certify that I (or my dependent) have coverage with my insurance as presented and assign directly to Kaplansky Foot & Ankle Centers all insurance benefits payable to me for services rendered. I understand I am responsible for deductibles, co-payments, and/or non-covered services. I authorize the doctor to release information necessary to secure payment of benefits, and authorize the use of this signature on all insurance submissions.
Guarantor / Financially Responsible Party (if different than above)
Summary of Notice of Privacy Practices
Uses and Disclosures of Health Information: We will use and disclose your health information to treat you, to obtain payment for services, and for certain limited operational activities such as quality assessment, licensing, accreditation, and training of students.
Uses and Disclosures Based on Your Authorization: Except as detailed in the full Notice of Privacy Practices, we will not use or disclose your health information without your written authorization.
Uses and Disclosures Not Requiring Your Authorization: We may disclose your health information without written permission to family/friends involved in your care, for limited research, for public health and safety, to government authorities regarding abuse or violence, to the FDA, to law enforcement, or as otherwise required by law.
Patient Rights: You have the right to access or copy your health information; receive an accounting of certain disclosures; request restrictions on use/disclosure; request confidential communication; request amendment of your records; and receive notice of our privacy practices.
If you have a question, concern, or complaint regarding our privacy practices, please ask for a copy of the full Notice of Privacy Practices and the name of the person to contact.
Kaplansky Foot & Ankle Centers — Office Policy
Appointments: If you are unable to keep an appointment, please call the office to reschedule at least 24 hours in advance. Patients who no-show/no-call three appointments may be asked to transfer their records to another doctor. Patients who are 15 minutes late may be asked to reschedule.
Kaplansky Foot and Ankle Centers reserves the right to terminate the doctor-patient relationship for the following reasons:
1. Treatment non-adherence — the patient does not follow the treatment plan.
2. Follow-up non-adherence — repeated cancellations or no-shows.
3. Office policy non-adherence — using on-call/multiple providers to obtain refills outside policy.
4. Verbal abuse — rudeness, improper language, violent behavior, or threats toward staff.
5. Nonpayment — declined to work with the office to establish a payment plan.
Acknowledgment of Receipt
I acknowledge that I was provided a copy of the Notice of Privacy Practices and the Office Policy, and that I have read (or had the opportunity to read) and understand both.
