Welcome to the Advanced Foot & Ankle Care!

We would like to take this opportunity to say “Welcome” to our practice. At Advanced Foot & Ankle Care, LLC., we are dedicated to the care of our patients. Wwe look forward to meeting your needs and appreciate the opportunity to do so, as we provide excellent Podiatry care for all of our patients.

For your convenience, our office hours are Monday through Friday, 8:30a.m. until 4:00p.m. To offer extra expediency to your experience, you may also request an appointment by accessing our website at www.AFAC.Bava.cox.com. Simply click on the blue button and follow the instructions.

To allocate for completion of new patient registration, we have prepared this patient packet for you to complete prior to your appointment in order to help make your visit a convenient and pleasant experience. If there is allotted time, the completed paperwork may be mailed and/or faxed to us prior to your appointment. Please keep a copy on file in the event that the package is lost. If your appointment is within 24 hours of receipt of this package, please bring the completed forms with you to your appointment. Please arrive thirty minutes prior to your appointment for your first visit; for subsequent appointments, please arrive fifteen minutes in advance of your scheduled appointment time.

Submit the following to Advanced Foot & Ankle Care, prior to your appointment:

Written Referral (If required by your insurance company) Completed Registration Form Completed History Form Completed and Signed Financial Policy Form List of Medications Photo ID Completed Sports Medicine History Form (If a sports or exercise injury) Medical Insurance Card Previous x-rays and medical records, if applicable Shoes (bring a sample, only need one shoe per pair, of the more common shoes you wear - including athletic and walking shoes)

Please be prepared to pay for the following at the time of your visit:

• Co-Payment (if applicable) • Deductible (If not fully paid for this year) • If no insurance, the full cost of visit {Note: For your convenience, we do accept Visa and Master Card.}

Our entire staff is here to help you in whatever manner we can. We look forward to serving you in the near future.

Your Scheduled Appointment is ______at ______AM/PM with Dr. Joseph V. Bava.

As a courtesy to other patients who are waiting to get in, please call at least 24 hours in advance if you must cancel your appointment. We reserve the right to charge for missed appointments. FINANCIAL POLICY We Accept Visa and Mastercard

Welcome To Our Office

Thank you for choosing us as your podiatric physicians. We are committed to your treatment being successful, as you, the patient, are our first and foremost concern. We focus on providing the best available care and want our billing service to be as easy as possible. In an effort to do this, we have outsourced our billing to CMOCC. The billing process can sometimes be complex, so we would like to prepare you for what to expect.

BILLING PROCESS:

Upon complete registration, your insurance will be verified immediately. This will allow CMOCC time to contact you via email, fax, or phone in regards to your co-pay, deductibles, coinsurance, unpaid deductibles, referral status, and/or self-pay status. You are required to pay any balance due at the time of service.

A claim will be sent to your insurance company within 24 hours of being seen. After receiving the claim, the insurance company may contact you for more information. Your quick response to their questions will assist your insurance company in processing your claim in a timely manner. It usually takes 14 – 30 days for the insurance company to pay your claim. After we receive your insurance eob {explanation of benefits}, we will provide you with a statement showing the insurance payment/denial and any amount you may owe. Please keep in mind that your policy is a contract between you and your insurance company.

In the event a patient does not have an insurance card on file, or does not have required referrals or pre-authorizations on file, there will be a $150 fee to be paid prior to seeing the doctor. If tests or procedures are performed during the visit, additional charges may be due at the end of the visit. Once we receive appropriate insurance documentation, your insurance company will be billed and you will be promptly refunded after the insurance company remits payment.

You cannot assume that your referral has been approved unless you have received written confirmation from your insurance company. If you are not sure your referral has been approved, please contact your insurance company prior to your appointment. If we do not have a paper copy of the referral in the office you may be financially responsible for the appointment, unless other arrangements are made with CMOCC at the time of service.

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Advanced Foot & Ankle Care along with CMOCC has implemented a Financial Policy. The following is a statement of our FINANCIAL POLICY which we request you read and sign prior to any treatment.

INSURANCE: If your doctor is a participating provider with your insurance plan, we will submit the claim to your insurance company. To do this we must have complete and accurate insurance information and a copy of your identification card or claim form. Your insurance policy is a contract between you and your insurance company; therefore you are responsible for payment whether or not your insurance company pays. It is your responsibility to contact your insurance company regarding pre- authorizations, obtaining required referrals, second opinions, etc. Failure to do so may reduce the amount of benefits paid by your insurance, and the balance will then become your responsibility to pay. All co-payments must be paid at the time of service.

NO INSURANCE: If you do not have insurance or the doctor is not a participating provider with your insurance plan, please be prepared to fully cover the fees for each visit at the time of treatment unless other arrangements has been made with CMOCC prior to your appointment date. PAYMENT: Payments for the balance due, co-payments, deductibles, etc., are due at the time of service and may be made by cash, check or credit card (Visa, MasterCard, Discover). There will be a $35.00 charge for returned checks.

CO-PAYMENTS: Please be prepared to pay all co-payments at the time of service. We do not send bills out for co- payments, so your visit will have to be re-scheduled if you are not prepared to pay the co-payment. Per our contract with the insurance carriers, we can not submit a claim without first collecting the co-pay from the policy holder/dependents.

DEDUCTIBLES: If you have an annual deductible which has not yet been paid in full then any charges incurred up to that amount are due at the time of your visit.

DELINQUENT ACCOUNTS: Any outstanding patient balances 30 days or more will be forwarded to CMOCC collection department. A 33.33% fee will be added to the balance by CMOCC collection department. The 33.33% will be paid by the patient, in addition to any court costs or fees if applicable.

MINOR PATIENTS: The adult or the parent (custodial guardian) accompanying a minor is responsible for payment of services. For unaccompanied minors, non-emergency treatment will be denied unless prior authorization from the parent or guardian has been made for the charges and treatment. Young adults (age 18 & over) are legally responsible for their accounts unless a parent accompanies them to the initial appointment and signs this financial agreement, regardless of insurance coverage.

MISSED APPOINTMENTS: Please help us serve you better by keeping scheduled appointments. If it is necessary to cancel, please call our office 24 hours in advance. This allows us to accommodate our other patients. We reserve the right to charge a fee of $45.00 for missed appointments.

ORTHOTICS: Orthotics are a non-covered service by some insurance plans. Please check with your insurance company prior to the examination and casting for orthotics to determine your orthotic benefits. A deposit of $150.00 is requested at the time of the examination and casting and full payment is due when the orthotics are dispensed.

SUPPLIES: For your convenience we make some supplies available for purchase in the office. If you choose to purchase these items, payment is due at time of purchase. We cannot bill for these items. In addition, we contract with outside suppliers to provide some supplies through our office. If any of these supplies are used for your treatment you or your insurance will be billed for these supplies by the outside provider. Advanced Foot and Ankle Care has no part in billing for these supplies.

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I have read and agree to the terms set forth in the above financial policy. I understand that all billing aspects of my account have been outsourced to CMOCC. Therefore, by signing below I agree that CMOCC has access to my account and may contact me regarding my account. As well as I must contact CMOCC directly regarding any questions and/or concerns regarding my billing account with Advanced Foot & Ankle Care, LLC. I acknowledge that I am financially responsible for any balance due.

Signature______DATE______Patient/Guarantor

Witness______DATE______AFAC Employee Signature

PATIENT INFORMATION Patient Name: LAST FIRST M.I. Male

Female Date of Birth: Age: Single Social Security Number: Married

Divorced Widowed Patient’s Address: City: State: Zip:

Email Address: Home Phone: Cell Phone:

Employer: Occupation: Work Phone:

Emergency Contact: Phone Number:

INSURANCE INFORMATION Name of Insured (if other Insured Date of Birth: Effective Date: than self):

Primary Insurance Policy Number: Group Number: Company:

Patient is Subscriber Spouse Dependent

Name of person Is a referral required for today’s visit? responsible for paying the bill (guarantor): Yes No

Same as patient Same as insured Guarantor’s address: Guarantor’s telephone#:

MVA or WC INJURY Date of injury: Type of injury:

work auto other Has claimed been filed? Claim # Where was claimed filed?

Yes No Case Manager Name: Case Manager Telephone#:

Cause of injury: REFERRAL

Referring Physician Name: Telephone Number:

Last Office Visit Date with Have you obtained a referral? Referring Physician: Yes No Pending

Primary Care Physician Phone #: and Clinic

SIGNATURE

I authorize my insurance benefits to be paid directly to Advanced Foot and Ankle Care, LLC. I understand that Advanced Foot & Ankle Care, LLC will bill my insurance as a courtesy and that I am responsible at the time of service for all co-payments, deductibles and non-covered services. I authorize the release of information required to process my claims.

Patient/Guarantor Date:

Advanced Foot & Ankle Care, LLC./Employee Date:

MEDICAL HISTORY ~ CONFIDENTIAL INFORMATION Patient Name: Last First M.I Date of Birth

What is the chief complaint(s) which brings you to Advanced Foot & Ankle Care, for medical treatment?

FOOT ANKLE LEG KNEE HIP

Which Side: Right Left Both Type of Pain: Dull Achy Throbbing Burning Sharp

{ } Shooting Duration: ______Days Weeks Months Years Onset Slow Sudden Traumatic

What is your What is your height: ______What is your shoe size:______weight:______

Any previous injuries or problems to the feet, ankles or legs? Yes {___} No {___}

EXERCISE AND ORTHOTICS SYMPTOMS MENTAL/EMOTIONAL Has pain gotten: Better Worse In what athletic activities do you participate? ____yes _____no Eating Disorder Stayed the Same ___yes _____ no Anxiety What aggravates condition? ______yes _____ no Depression __ ___yes _____ no Psychiatric Walking Running How many days per week do you exercise? ___yes _____ no Alcoholism Standing Shoes {__}0 {__}1 to 3 {__}4 to 6 {___}7 How long does pain last? Do you wear store-bought arch supports? SOCIAL HISTORY {___} yes {___}no

Your occupation? What have you tried to help the pain? Do you wear custom orthotics? ______

_____Changing shoes {___} yes {___}no Do you smoke? {___} yes {___}no _____Anti-inflammatories If yes, who made them: _____Decrease activities Are you a past smoker? {___} yes {___}no ______Arch Supports or Orthotics How Many Packs a day?______Ice _____Stretch How old are the orthotics: Years Smoked:______Other:______Surgeries, Injuries, Illnesses Have you ever had a similar pain? (describe, including treatment List surgeries, serious injuries, and illnesses not previously listed: received) ______Yes ______No ______Personal Personal Family Member Family Member

{_} yes { _} no Anemia {_} yes { _} no Kidney Problems {___} yes {_} yes { _} no Arthritis: {__} yes {_} yes { _} no Leg Cramps Type:______{_} yes { _} no Liver Disease {_} yes { _} no Artificial Heart {___} yes Valve or Joints {_} yes { _} no Lung/Respiratory {_} yes { _} no Asthma {___} yes {___} yes {_} yes { _} no Menopause {_} yes { _} no Back Problems {_} yes { _} no Mental Illness {_} yes { _} no Bleed easily {___} yes {___} yes {_} yes { _} no Phlebitis / Clots {_} yes { _} no Cancer {___} yes {___} yes {_} yes { _} no Psoraisis {_} yes { _} no Chemical {___} yes {___} yes Dependency {_} yes { _} no Rheumatic Fever

{_} yes { _} no Chest Pain {_} yes { _} no Stroke {___} yes {___} yes

{_} yes { _} no Circulatory {_} yes { _} no Thyroid Problems {___} yes Problems {_} yes { _} no Tuberculosis

{_} yes { _} no Diabetes {_} yes { _} no Ulcers—Stomach {___} yes {_} yes { _} no Venereal Disease {_} yes { _} no Epilepsy {___} yes {_} yes { _} no Weight Change,

{_} yes { _} no Fibromyalgia Recent. _____lbs

{_} yes { _} no Gout

{_} yes { _} no Heart Disease {___} yes

{_} yes { _} no Hemophilia {___} yes

{_} yes { _} no Hepatitis

{_} yes { _} no High Blood Pressure {___} yes

{_} yes { _} no HIV Positive PATIENT NAME______DATE OF BIRTH: ______Last First MI AGE

LIST ALLERGIES AND REACTIONS

NO ALLERGIES

ALLERGY REACTION ALLERGY REACTION

LIST ALL CURRENT MEDICATIONS INCLUDING OVER THE COUNTER, HERBAL SUPPLEMENTS, AND VITAMINS

NO MEDICATIONS

MEDICATION NAME DOSE HOW OFTEN PRESCRIBED FOR:

Example Medication 10 mg Twice a day Back pain

For Office Use Only:

Medical Assistant Review ______initials Physician Review ______initials

Date______Date______