Chart #
Patient Name:_________________________________ DOB:______________
Describe your foot problem?
_____________________________________________________________________________________
_____________________________________________________________________________________
What medications do you take regularly?
_____________________________________________________________________________________
_____________________________________________________________________________________
List any allergies:
_____________________________________________________________________________________
Any previous surgeries?
_____________________________________________________________________________________
PROBLEMS/ROS
[ ] Heart
[ ] Asthma or Breathing Difficulty
[ ] Scarring Tendency
[ ] Diabetes
[ ] Stomach Ulcers
[ ] Gout
[ ] Circulation
[ ] Hormones
[ ] Tuberculosis
[ ] Arthritis
[ ] Anemia
[ ] Rheumatic Fever
[ ] Kidneys
[ ] Bladder
[ ] Liver [ ] Spleen
[ ] Lungs
[ ] High Blood Pressure
[ ] Eye, Ear, Nose or Throat
[ ] Cancer__________
[ ] Hepatitis A-B-C
[ ] Unexplained Fever
[ ] HIV Positive/AIDS
[ ] Convulsions
[ ] Weight loss
[ ] Strokes
[ ] Numbness in feet___ or legs___
[ ] Skin
[ ] Bleeding Tendency
[ ] Cramps in feet___ or legs___
[ ] Frequent infections
[ ] Healing
[ ] Emotional or psychiatric disorder
[ ] Neurological Disorder
Any artificial joints?
Any metal (pins, plates, etc.) in your body?
[ ] HIP [ ] KNEE
[ ] YES
[ ] NO
[ ] Other_____________
Where?_________________________
Do you have any artificial Heart Valve Implants? YES NO
FAMILY HISTORY
Mother
LIVING
DECEASED
Cause of death__________________________
Father
LIVING
DECEASED
Cause of death__________________________
Brother
LIVING
DECEASED
Cause of death__________________________
Sister
LIVING
DECEASED
Cause of death__________________________
Check [ ] and list family members (blood relative) history of:
[ ] Heart Disease_________________________________________________________
[ ] Arthritis______________________________________________________________
[ ] Bleeding Disorder______________________________________________________
[ ] Neurological Disorder___________________________________________________
[ ] Stroke________________________________________________________________
[ ] Circulation problems in legs or feet_________________________________________
Do you Smoke? YES NO
Previously smoked? YES NO
Do you drink? YES NO
Are you pregnant? YES NO
DEALING WITH MEDICARE AND THEIR RULES
Medicare covers some medical/surgical services and does not cover others.
We will file your Medicare for covered services. Medicare will pay 80% of the
charges of which they approve after a $140 deductible has been paid.
We will file your companion insurance (supplement to Medicare) for the
remaining 20% of the covered services. You will be billed for any REMAINING
balance that your supplement does not pay, or if you do not have a Medicare
supplement. It will be your responsibility to pay any unmet deductibles.
Any charges that are for services NOT COVERED by Medicare are due and
payable at the time of service. Currently, Medicare Part B will not pay for ROUTINE
FOOT CARE which includes nail trimming, corn or callous trimming, and custom
shoe inlays and surgical shoes. Also Medicare will not pay for subluxation(755.69)
and treatment of the flat foot (754.61).
The following service(s) are not covered by Medicare policy. If these
determinations are made by Medicare, you agree that you have been informed
before the services(s) was rendered, and that you agree to be responsible for
payment of the specific services listed below.
Service Code
L3211
L3260
11055-11057
11720-11721
A9160
29540
Procedure Description
Surgical Shoe
Surgical Boot
Corn or Callous Paring
Debridement of Nails
Noncovered Footcare
Ankle\Foot Taping
Estimated Charge
$25.00
$105.00
$45-75
$40.00
$40.00
$33.00
I agree to be personally and fully responsible for payment of the above services.
Brian E Sicher, DPM or Mark A Gerig, DPM may disclose all or part of this patient’s
record to any insurance company, physician, clinic, hospital or laboratory. I
understand that the information released may include information pertaining to
mental or psychiatric related problems. A copy shall be valid as the original.
SIGNATURE____________________________________ DATE________________
WITNESS
____________________________________ DATE________________
RECEIPT ACKNOWLEDGMENT
OF
NOTICE OF PRIVACY PRACTICES
I acknowledge that I understand the notice and have the opportunity to read the Notice of Privacy
Practices if I so choose (posted in our office) or I can be given a copy if requested.
_____________________________
______________
Patient Name (please print)
Date
_____________________________
____________________
Parent or Authorized Representative
E-mail Address / IQ HEALTH
_____________________________
Signature
PATIENT INFORMATION
Patient Name ___________________________________ Sex: F___ M ___ Date _____________
Address ______________________________City _________________ State ___ Zip _________
Home Phone (
)_____________ Cell (
)______________ Work (
) ______________
Date of Birth ________________________ Age ________ SS# ___________________________
Patient’s Employer _______________________________ Occupation ______________________
Name of Insurance _____________________ Policyholder’s Name ________________________
Policyholder’s Address ________________________________ Phone ( ) _________________
Policyholder’s Date of Birth ________________ Policyholder’s SS# ________________________
Spouse’s Name ________________________ If Minor, Parents’ Name _____________________
Spouse’s Employer _____________________
Nearest Relative _____________________ Address ______________________Phone_________
Referred By: __ Physician (Name) __________________
__ Patient (Name) ____________________
__ Phone Book
__ Other _____________________