ta’lus inMotion Foot & Ankle
REGISTRATION FORM (Please Print)
First Name: _______________________________MI:_________ Last Name: ________________________________________
Sex: M/F SS#: _____________________Date of Birth: _____________ Email address: __________________________________
Address: ___________________________________________ City: ____________________ ST: _______ ZIP: ____________
Home phone #: (___) _________________ Work phone #: (___) ____________________Cell #: (___) _____________________
PRIMARY CARE PHYSCIAN: ______________________________ PHONE #:___________________LAST SEEN_________
REFERRED BY: ________________________________________________________________________________________
Primary Language: ______________________ Race: ______________________
Hispanic or Latino / Not Hispanic or Latino
EMERGENCY CONTACT: ___________________________________________ Phone #: ______________________________
Marital status: S M D W Employer: ___________________________ Occupation: __________________________________
PHARMACY NAME: _______________________LOCATIONS: ______________________PHONE #: ___________________
INSURANCE INFORMATION
Primary Insurance: Policy Holders Name: ________________________________________________Date of Birth: ______________
Relationship to Policy Holder: __________________________
Secondary Insurance: Policy Holders Name: _____________________________________________Date of Birth: _______________
Relationship to Policy Holder: ___________________________
CONTACT CONSENT
Home Phone Number: (___) ___________________________Alternate Number: (___) ______________________________
May our office staff leave any messages on your home answering machine or cell phone regarding appointments, billing
questions or medical information? Yes _________
No _________
May our staff leave a message at your work place? Yes _________
No _________
Please list the names of any individuals that our office staff had permission, which is given by you, to speak with:
Name: _________________________________Relationship:__________________Phone #: (___) _______________________
Name: _________________________________Relationship:__________________Phone #: (___) _______________________
I hereby give ta’lus inMotion permission to treat me or my dependants as necessary. I understand my insurance company may assist me in paying all medical costs, but I am
ultimately responsible for all medical services rendered and if necessary, I agree to pay all reasonable and customary collections fees and /or attorney’s fee that may be incurred due
to any delinquent accounts I may have. I authorize the release of any medical information necessary to process my claim to my insurance company. I furthermore authorize
payment of medical benefits to my physician, directly, for server ices rendered. I understand that I am financially responsible for my bill. I also authorize ta’lus inMotion to release
any information required to process my claims.
**As a courtesy, we will bill your Insurance Company for you**
Patient/Guardian Signature: _______________________________________ Date: ___________
PERSONAL HEALTH HISTORY
LIST YOUR PRESCIBED DRUGS AND OVER-THE-COUNTER DRUGS, SUCH AS VITAMINS AND INHALERS
Name of drug
Strength
Frequency taken
ALLERGIES TO MEDICATIONS
Name of drug
Reaction You Had
SURGERIES/HOSPITALIZATIONS
Year
Reason
Hospital
DO YOU HAVE A PERSONAL HISTORY OF: (Please circle YES or NO)
Y/N Anemia
Y/N Diabetes
Y/N Hypothyroid
Y/N Arthritis
Y/N Foot Numbness
Y/N Kidney Disease
Y/N Asthma
Y/N Heart Problems
Y/N Leg Cramps
Y/N Bleeding Disorder
Y/N Hepatitis
Y/N Neurological Disease
Y/N Cancer
Y/N High Blood Pressure
Y/N Phlebitis
Y/N Circulation Problems
Y/N High Cholesterol
Y/N Other____________
Have you ever had a blood transfusion? Y/N
Do you smoke cigarettes? Y/N
Did you smoke? Y/N
How much? _________________ How many Years? ___________
Do you drink alcohol?
Y/N
Did you drink?
Y/N
How Much? _________________ How many years? ___________
FAMILY MEDICAL HISTORY: Which of the following illnesses are in your IMMEDIATE family (father, mother, brother,
sister) Example: Cancer-Father)
Heart Disease: _______________________Cancer: ____________________________ Arthritis: ________________________
Diabetes: __________________________ High Blood Pressure: ______________________ Other: _____________________
REVIEW OF SYSTEMS (Please circle any symptoms you are CURRENTLY experiencing or mark the “unremarkable”
column if none apply)
Unremarkable Symptoms
Allergy/Immunology
Cardiovascular
Constitutional
Ear/Nose/Throat/Eyes
Endocrine
Gastrointestinal
Genitourinary
Hematologic/Lymphatic
Musculoskeletal
Neurologic
Psychiatric
Respiratory
Skin
Rash, difficulty breathing, drug allergy, gout, receives allergy shots
Chest pain, palpitations, calf pain, back pain
Fever, weight gain, weight loss, nausea, vomiting, chills
Vision changes, hearing loss, sore throat, retinopathy
Dry skin, dry eyes, weight change, frequent urination
Stomach ulcerations, abdominal pain, GI upset, acid reflux, diarrhea, constipation
Painful urination, frequent urination
Uncontrollable bleeding, swollen lymph nodes
Arthritis in knee, hip, ankle, big toe joint, back, shoulder, spine, injury, fracture, gout
Numbness, tingling, electrical pain, difficulty walking, confusion, burning, weakness
Crying, depression, addiction, anxiety, poor anger control, recent stress, forgetfulness,
constant overeating
Shortness of breath, difficulty breathing, wheezing, coughing
Skin cancer, burns, nail fungus, athlete’s foot, rash, ulcer, wound, prolonged healing
time
OFFICE/FINANCIAL POLICIES
Effective July 1, 2014
Thank you for choosing ta’lus inMotion Foot & Ankle as your medical provider. Please carefully read and sign below. This policy
has been put into place to ensure that financial payments due are recovered to allow us to continue to provide quality medical care for
our patients. It is important that we work together to assure that payment for services is as simple and straightforward as possible. Our
staff will be glad to discuss these policies with you.
I understand that if I do not have my insurance card, referral/prior authorization and/or co-payments the day of my appointment, that
my appointment may be rescheduled until such a time that I can provide documents or payments.
I understand that ta’lus inMotion Foot & Ankle will collect, prior to any office visit and procedure, deductible and coinsurance up to
an amount equal to payment in full for the planned office visit. Payment in full and expected coinsurance payment responsibility are
determined by the anticipated medical billing code(s), details of your insurance policy and agreement between your insurance
company and ta’lus inMotion Foot & Ankle. It is recommended that you call your insurance company to verify your coverage.
If full deductible is not applied to your claim by your insurance company, we will refund any overpayment to you within 30 days of
the date we receive the overpayment.
ta’lus inMotion Foot & Ankle will allow 60 days from the date of filing for my insurance company to process or pay a claim.
Arizona law allows insurance companies operating in the state no more than 30 days to process claims. It is my responsibility to
provide my insurance company with requested information needed to process a claim service. It is also my responsibility to notify
ta’lus inMotion Foot & Ankle if there are any changes in my insurance coverage, residence or phone number.
Ultimately, it is up to me to know my insurance benefits.
I understand that if my account is not paid in full within 90 days, a $20.00 collection processing fee will be added to the outstanding
balance and will be turned over to collections for further processing. No additional appointments will be made for delinquent accounts
until they are brought current.
I understand that I may be charged a $50.00 fee for any missed appointments not canceled with at least a 24-hour advanced notice. I
also understand that if I am late for my appointment that I may not be seen that day and will need to reschedule.
I understand that a $35.00 service fee will be added for any checks returned for any reason and I will be responsible for payment of
this fee and the amount of the returned check. NSF checks must be redeemed with certified funds (cashier’s check, money order or
cash).
DOCUMENTATION FEE: There will be a service fee of $25.00 or more for all documents/letters that need to be completed by the
provider. The fee will be determined by the complexity of the document requested.
MEDICAL RECORDS REQUEST: There will be a $10.00 plus .10cents per page fee for patients requesting a copy of their
personal medical records and $5.00 for a CD copy of X-rays. Medical records will be sent to another provider at no charge.
SURGICAL FEES: I understand that prior to my surgery date I will be responsible for a deposit of $500.00, depending on my
insurance deductible and/or coinsurance. I also understand that if I am unable to keep my scheduled surgery I must contact
ta’lus
inMotion Foot & Ankle at least two business days prior to my scheduled surgery date or a $250.00 fee will be assessed.
CUSTOM ORTHOTICS: I understand that ta’lus inMotion Foot & Ankle does not bill ANY Insurance companies for custom foot
orthotics. The cost is $495 and a $250 deposit is due at the time of casting.
MINOR AGE PATIENTS: ta’lus inMotion Foot & Ankle requires that a parent or legal guardian accompany all minor patients.
The parent or legal guardian that accompanies the minor for medical services will be responsible for payment.
RELEASE OF INFORMATION: I authorize ta’lus inMotion Foot & Ankle to release any information acquired in the course of
my treatment as required for processing insurance claims. I also authorize the release of my medical information to any requesting
source presenting a signed authorization by me.
AUTHORIZATION TO TREAT: I hereby authorize the staff of ta’lus inMotion Foot & Ankle to provide me with medical
treatment. I agree to inform them if I have any concern about my medical treatment at the time the services are being rendered.
I have read and understand the above Office/Financial policy and I agree to abide to its terms.
_______________________________________
_____________________________________________
___________________
Printed name of Patient
Signature of Patient/Responsible Party
Today’s Date
DIRECT PAYMENT NOTIFICATION
The Arizona State Constitution permits you to pay a healthcare provider directly for health care services. Before
you make any agreement to do so, please read the following important information.
If ta’lus inMotion Foot and Ankle is contracting with your insurance, the following guidelines apply:
1. You may not be required to pay the ta’lus inMotion Foot and Ankle directly for the services covered
by your plan, except for cost-share amounts that you are obligated to pay under your plan, such as
copayments, coinsurance and deductible amounts. Non-covered services such as PalinGen Flow
(Amnio), PRP, Shockwave, Custom Foot Orthotics, Prefabricated Orthotics, Laser Therapy and Fungal
Toenail Laser Therapy.
2. ta’lus inMotion Foot and Ankle agreement with your insurance may prevent ta’lus inMotion Foot and
Ankle from billing you for the difference between ta’lus inMotion Foot and Ankle billed charges and
the amount allowed by your health plan for covered services.
3. If you pay directly for a health care service, ta’lus inMotion Foot and Ankle is not responsible for
submitting claim documentation to your insurance. Before paying your claim, your health plan may
require you to provide information and submit documentation necessary to determine whether the
services are covered under your plan.
4. If you do not pay directly for a health care service, ta’lus inMotion Foot and Ankle may be responsible
for submitting claim documentation to your health plan for the health care service.
Your signature below acknowledges that you received this you received this notice before paying
ta’lus inMotion Foot and Ankle directly for a health care service.
Signature: _________________________________________ Date: ______________________
Print Name: _______________________________________
ta’lus inMotion Foot & Ankle
ACKNOWLEDGEMENT OF RECEIPT
OF
NOTICE OF PRIVACY PRACTICES
I acknowledge that I was provided a copy of the Notice of Privacy Practices and
that I have read (or had the opportunity to read if I so chose) and understand the Notice.
____________________________________________
Patient Name (please print)
_____________________________________________
Responsible Party Signature
______________________
Date