First Time Arrival Checklist Items to bring:

Registration Form completed

Consent to Treat/Acknowledgement of FinancialResponsibility/Notice of Privacy Practices AcknowledgementForm Signed

Medical History Form completed

Vascular/Neurological Screening Form completed if one of thefollowing applies:

o Diabeteso Over 65, (50 with diabetes)o Smokeo History of known heart disease

Personal Representative Authorization Form completed(optional see form for details)

All insurance cards and an identification card with a your photo

Up-to-date list of all medications

After arrival: We are required to have you sign an acknowledgement that you have received the Notice of Privacy Practices that was included with this packet.

Welcome to Centers For Foot & Ankle Care!

Our Mission: The podiatrists at Centers For Foot & Ankle Care are dedicated to providing you the highest quality foot care. Our practice includes doctors, medical assistants and receptionists who share a commitment to providing the best possible care for you or members of your family.

Complete Foot & Ankle Care: Centers For Foot & Ankle Care specialize in the treatment of any foot or ankle related pain, sports injuries, diseases or other problems. The most common conditions we see include heel and arch pain; diabetic foot care; ingrown and fungal nails; fractures and sprains; corns and calluses; bunions; hammertoes; endoscopic surgery for heel spurs and pinched nerves; reconstructive foot and ankle surgery; and ankle arthroscopy. In addition, we provide pediatric medical and pediatric surgical care.

Scheduling Appointments: When you need an appointment, we ask that you call our office directly. Our receptionist will take your basic information and will ask you the reason for your visit. This is important information so that we can schedule enough time for your appointment with the doctor. Our office hours are generally 9 a.m. to 5 p.m., Monday through Friday with occasional Saturdays and extended hours at certain locations.

Registration: Each time you arrive for your appointment, you will be asked to present your insurance card and verify your address and phone number. While this may seem like an inconvenience, weve found that often the insurance companies make slight changes to the coverage that are important for us to know. Please be prepared to present this information to the receptionist upon checking in for your appointment. Our goal is to have you in the exam room and prepared to see the doctor at your scheduled appointment time. If there are changes in your address, phone number or insurance information, please plan to arrive 10 minutes prior to your scheduled appointment to complete the needed paperwork.

Referrals: If your health plan requires referrals, please be sure that your primary care physician has completed this process before your visit. If this process has not been completed and approved by your insurance company, you may be subject to the entire cost for the visit.

Payment Policy: At the time of service, Centers For Foot & Ankle Care collects any insurance-required copayments and known deductibles. Overpayments collected may be applied to any outstanding balance or refunded according to your insurance policy requirements. If your copayment is not paid at the time of service, CFAC reserves the right to assess a $20.00 fee to the patients account. For your convenience, we accept cash payments, personal checks, Visa, MasterCard, Discover, and American Express.

Returned Check Reprocessing Charge: Centers For Foot & Ankle Care will assess a $20.00 Returned Check Reprocessing Fee for each check returned unpaid by our bank.

After Hours Protocol: In the event that you need care after hours or on weekends, Centers For Foot & Ankle Care has staff available. Please phone the office and listen for information on having the on-call physician or other staff paged.

Treatment of Minors Policy: Patients under the age of 18 must have a parent/legal guardian present to complete initial paperwork and treatment consent. All minors must have written parental consent with each subsequent office visit, even if they are accompanied by an older sibling, babysitter or grandparent. Without parental consent, the childs appointment will have to be rescheduled. A parent/legal guardian must be present when routine care/injections are administered.

Medication Refill Policy: As part of your medical treatment, our physicians may prescribe medications to be filled by your pharmacy. If you are on regular medications, you may need to have the prescription refilled. Be sure to call our office well in advance of the time your refill is needed.

Follow-up appointments to monitor your progress on medication are very important. When our physicians see you in the office, they will write your prescription with a certain number of refills. If you are due to come into the office for follow-up care, we may not accommodate your request to phone your refill into your pharmacy.

When you come to our office for your visit, be sure to bring an up-to-date list of all medications you are currently taking.

Missed Appointment Policy: We realize that circumstances may cause you to arrive late or miss an appointment. CFAC asks that you call the office at least 24 hours in advance in cases where you know that you are unable to keep your appointment. If you know you will be late, please call us at least 30 minutes in advance.

If you arrive 15 minutes late or more without advance notice, you may be asked to reschedule. If you miss an appointment without giving us advance notice, CFAC reserves the right to charge $20.00 for the missed appointment time. A pattern of missed appointments may result in your dismissal from Centers For Foot & Ankle Care

Billing Office: If you have questions or concerns about your bill or need to set up payment arrangements, please feel free to contact our billing office directly at 513-619-6800.

Release/Transfer of Medical Records: CFAC requires an administrative fee for the retrieval, duplication and transfer of a patients medical chart. This fee covers the cost of the duplication and any applicable postage to forward those medical records. Prior authorization from the patient is required before any copies are released. CFACs fee policy for the transfer of records is in accordance Office of Civil Rights under 45 CFR 164.524(C)(4), with the maximum charge as follows:

o $6.50 Flat Fee Chargeo Only the last two years of the record will be copied.

After receiving your authorization for release/transfer of records you will be sent a letter stating the cost for the transfer. Upon receipt of your payment, CFAC will forward a copy of the last two years of your medical record to the physician/facility you have designated.

Consent to Treat/Acknowledgement of Financial Responsibility The undersigned patient or individual acting on behalf of the patient agrees as follows:

1. Authority is granted to Centers for Foot and Ankle Care to render needed treatment and/or tests to the patient.

2. I authorize Centers for Foot and Ankle Care to release any information required for payment of insurance claims.

3. I authorize my insurance or Medicare benefits to be paid directly to the treating physician, realizing I am responsible to pay non-covered and unauthorized services.

4. I understand that I am responsible for all charges incurred through Centers for Foot and Ankle Care. Payment is expected at the time of my visit. If this cannot be done, I agree to make other arrangements with the office. I also agree to pay any collection or attorneys fees incurred above and beyond the past due amount.

5. I have been given Centers for Foot and Ankle Cares handout on missed appointments and understand my responsibilities regarding being late or absent.

6. Parent or legal guardian consent must be provided for treatment of a child (under the age of 18) for every visit. If you are unable to accompany your child to each visit, you may designate specific person(s) (adults over age 18) below as giving consent to treat for your child on your behalf.

Name ______________________________________________ Relation to child _____________

7. In the event of an emergency, I designate the following person as my emergency contact:

Name _______________________________________________ Home phone ___________ Address _____________________________________ Other phone ___________ City/State/ Zip __________________________________________________________________

8. Expirations or termination of authorization: This authorization will remain in effect until terminated

by you, your personal representative or another individual(s) of legal entity authorized to do so by court order or law.

__________________________________________ ____________ Signature of Patient or Legal Guardian Date

Notice of Privacy Practices Acknowledgement I have received or been offered copy of this offices Notice of Privacy Practices.

__________________________________________ ____________ Signature of Patient or Legal Guardian Date

Registration Form

Last Name First Name MI Nickname DOB Account Number (Office)

Street Address City State ZIP Code

Home Phone Preferred Work Phone Preferred Cell Phone Preferred Social Security #

Sex: Male Female

Email Address

Emergency Contact Contact Phone Primary Care Physician

PRIMARY Insurance Name Copay $ SECONDARY Insurance Name Copay $

Claims Address P.O. Box Claims Address P.O. Box

Subscri