Fillable New Patient Form (Page 2 of 3) in pdf

CONSENT FOR TREATMENT

I give my consent to be treated by Jeremiah Graff, DPM, CWS at Texas Center for Foot & Ankle

Surgery/Texas Center for Advanced Wound Care or my residing facility. I understand that this is a

general consent, and that if I am to undergo surgery I will sign the appropriate informed consent form prior to

receiving that service.

CONSENT FOR PHOTOGRAPHS/VIDEO/MULTIMEDIA

I give permission to Texas Center for Foot & Ankle Surgery/Texas Center for Advanced Wound Care to

take pictures/video/multimedia for reference and charting purposes.

AUTHORIZATION FOR RELEASE OF INFORMATION

I authorize Texas Center for Foot & Ankle Surgery/Texas Center for Advanced Wound Care to release

medical, psychiatric and substance abuse information contained in my/the patient’s records to insurance

carrier(s), physicians or other healthcare practitioners. Unless noted below, medical records released may

include diagnostic and therapeutic information (including test for HIV antibody/substance abuse).

Withhold from release: (please specify if any)_____________________________________________

Information is disclosed from records whose confidentiality is protected by Federal and State law.

Federal regulations or State law prohibit making any further disclosure of HIV antibody/substance

abuse without the specific written consent of the person to whom it pertains or as otherwise

permitted by Federal/State law.

Please list the names of any other people your medical records and information may be provided to

(i.e. spouse, parent, caregiver, etc):

Name(s): ______________________________________ Relationship: ________ Phone:______________

PAYMENT POLICY

~By signing below I am providing “Assignment of Benefits” permission for Dr. Graff to file claims to my

insurance carrier on my behalf.

~All co-payments, co-insurance and deductibles must be paid at the time of service as required by the terms

of your health insurance provider. Please understand that failure on our part to collect these payments can

be considered insurance fraud. For your convenience we accept: MasterCard, Visa, Discover & AMEX.

~Please be aware that some of the services you receive may not be deemed medically necessary by your

insurance carrier, therefore, you will be responsible for payment of all services not covered.

~There is a $25 fee for paperwork that needs to be completed such as, but not limited to, disability

paperwork, copies of x-rays and medical records.

By signing below, I acknowledge that I understand the information on this document. I also permit a

copy of this to be used in place of the original.

___________________________________________________

____________________________

Patient/Guarantor Signature

Date

______________________________________________________________________________________

Patients Printed Name

6105 Windcom Court Suite 100, Plano, TX 75093

Phone 972.403.7733 Fax 972.403.7744

E-Mail texasfootsurgery@verizon.net

New patient form updated 12/18/13

New Patient Form Page 2