Medical Office Registration Form s10

Midwest Podiatry Services, a division of Reconstructive Foot and Ankle Surgery Pediatric Foot Disorders ▪ Diabetic Foot Care ▪ Sports Medicine Computerized Gait and Pressure Analysis ▪ Physical Therapy

Nicholas J Alianello, DPM Anthony H. Borrelli, DPM Jennifer L Kaleta, DPM Lowell Weil, Jr., MBA, DPM Jeffery H. Alexander,MS,DPM Michael F. Bowen, DPM Erin E. Klein, MS, DPM Lowell Scott Weil, Sr., DPM Gregory T. Amarantos, DPM Cynthia R. Cernak, DPM David W. O’Brian, DPM Stephen A. Weinberg, DPM Jeffrey R. Baker, DPM Kordai I DeCoteau, DPM Robert G. O’Keefe, DPM Bruce E. Williams, DPM George L. Enriquez, DPM Mitchell B. Sheinkop, MD Wendy Benton-Weil, DPM Adam E. Fleischer, MPH, DPM Matthew D. Sorensen, DPM Fellow, Brett J Waverly, DPM Jennifer E Bernstein, DPM Dr. Wika K Gomez, DPM Bilal Siddiqui, DPM Fellow, Sarah Haller, DPM Frank Bongiovanni, DPM Donna J Hayes, DPM Dean S. Stern, DPM Stephanie C. Spiegel, COO

Dear :

On behalf of all the associates at the Weil Foot & Ankle Institute, I would like to welcome you and your family. We take pride in knowing that you have placed your trust in us to provide for your care while being treated at the Institute. By having the best team and a focused facility, we are here to meet all of your podiatric needs.

Our patient-focused environment fosters open communication, cooperation, innovation, respect and compassion. Our staff is prepared to provide information you may need to prepare for the care you will be receiving at the Institute. Please ask any staff member if there is anything we can do to make your visit with us the best that it can be. We promise that our patients always come first.

Thank you for choosing the Weil Foot & Ankle Institute.

Sincerely,

Stephanie C. Spiegel Chief Operating Officer

1455 E. Golf Road ▪ Des Plaines ▪ Illinois ▪ 60016 ▪ T-847.390.7666 ▪ F-847.390.9345 Aurora ▪ Bridgeport ▪ Des Plaines ▪ Glenview ▪ Highland Park ▪ Kenosha ▪ Lake Forest ▪ Lakeview ▪ Libertyville ▪ Lincoln Park ▪ Merrillville ▪ Oak Lawn ▪ Oak Park ▪ Paddock Lake ▪ Ravenswood ▪ Roselle ▪ Rush University Medical Center

▪ WWW.WEIL4FEET.COM ▪ Midwest Podiatry Services, a division of Reconstructive Foot and Ankle Surgery Pediatric Foot Disorders ▪ Diabetic Foot Care ▪ Sports Medicine Computerized Gait and Pressure Analysis ▪ Physical Therapy

WELCOME TO OUR PRACTICE

This letter confirms your appointment with Dr. at on in the following office:

Copley, 2020 Ogden Ave, Suite 400, Aurora 60504 Oak Park, 610 S. Maple Avenue, Suite 2250 (60304) Rush University Medical Center, 1611 W. Harrison St., Suite 510, Chicago (60612) Glenview, 1300 Waukegan Rd. (60025)

Please Arrive at least 30 minutes prior to your appointment time to complete the registration process. Also enclosed please find our “New Patient” insurance information and medical history forms that we ask you to complete prior to your appointment. You may email or fax the completed forms to us at 708-660-0447 or bring the completed forms with you. If we do not have your completed forms before your appointment time, your appointment may be delayed by up to 30 minutes.

Please review this material and contact your insurance carrier about policy deductibles and co-insurance prior to your appointment. Feel free to call our office at 708-660-6100 with any questions.

Thank you,

Stephanie C. Spiegel Chief Operating Officer Weil Foot & Ankle Institute

1455 E. Golf Road ▪ Des Plaines ▪ Illinois ▪ 60016 ▪ T-847.390.7666 ▪ F-847.390.9345 Aurora ▪ Bridgeport ▪ Des Plaines ▪ Glenview ▪ Highland Park ▪ Kenosha ▪ Lake Forest ▪ Lakeview ▪ Libertyville ▪ Lincoln Park ▪ Merrillville ▪ Oak Lawn ▪ Oak Park ▪ Paddock Lake ▪ Ravenswood ▪ Roselle ▪ Rush University Medical Center

▪ WWW.WEIL4FEET.COM ▪ Midwest Podiatry Services, a division of

(Please Print) REGISTRATION FORM Today’s Date / / Facility Doctor PATIENT INFORMATION Patient’s Last Name First Middle Mr. Mrs. Sr. Dr. Miss Jr. Street Address City State Zip Code

Home Phone # Work Phone # E-mail Address ( ( ) - ( ) - Birth Date Age Social Security Number Marital Status Sex Single Mar / / Widow Div M F INSURANCE INFORMATION Occupation Insured Employer

Insured Employer Address

Please indicate primary insurance Address of primary insurance carrier Phone number

( ) - Insured Name Insured S. S. # Insured ID Policy Group # Eff. Date Co-Payment

$ Patient’s Relationship to Insured Self Spouse Child Other Insured Birth Date / /

Insurance Type PPO EPO HMO POS Self Pay Medicare Public Aid WC OTHER . Please indicate secondary insurance Phone number Address of secondary insurance carrier

( ) - Insured Name Insured S. S. # Insured ID Policy Group # Eff. Date Co-Payment

$ Patient’s Relationship to Insured Self Spouse Child Other Insured Birth Date / / Insurance Type PPO EPO HMO POS Self Pay Medicare Public Aid WC OTHER .

Referred to Institute by (Please use one) Address

Doctor

Hospital

Insurance Plan

Family

Friend

Tribune Herald Sun Times T.V Radio Other

AUTHORIZATION FOR ASSIGNMENT OF BENEFITS X / / To Weil Foot & Ankle Institute, Ltd. Signature Date

HIPAA AUTHORIZATION X / / Necessary to process claims Signature Date

COMMUNICATION AUTHORIZATION X / / I authorize Weil Foot & Ankle Institute to contact Signature Date me via phone, text, fax, mail and email

MEDICAL HISTORY PATIENT NAME BIRTH DATE / /

ALLERGIES (LIST KNOWN ALLERGIES OR REACTIONS TO DRUGS/MEDICATIONS

Penicillin Sulfa Local Anesthetic Anti-inflammatory Medication

Codeine Tape Nausea From Anesthetic Iodine on Skin

MEDICATIONS (PLEASE LIST CURRENT MEDICATIONS THAT YOU ARE TAKING: PRESCRIPTION AND OVER THE COUNTER) MEDICATION DOSE MEDICATION DOSE

HOW FOOT/ANKLE PAIN WHERE? LONG? MONTHS YEARS WHAT PREVIOUS TREATMENT HAVE YOU HAD ON YOUR FOOT/ANKLE?

Surgery Orthotics Oral Medications Cortisone Shots FAMILY PHYSICIAN INFORMATION Medical Doctors Name Phone Number

( ) - Street Address City State Zip Code

Have you ever been put to sleep for surgery? Yes No

SHOE SIZE HEIGHT WEIGHT

DO YOU DRINK? NO YES DRINKS PER WEEK

DO YOU SMOKE? NO YES PACK(S)/DAY Indicate which of the following you have had or have at present. Check Yes or No to each item

Arthritis/Rheumatism Yes No High Blood Pressure Yes No

Artificial Joints (hip, knee, etc.) Yes No H.I.V. Positive Yes No

Asthma Yes No Kidney Trouble Yes No

Diabetes Yes No Liver Disease Yes No

Fibromyalgia Yes No Motion Sickness Yes No

Glaucoma Yes No Neurological Disorder Yes No

Heart (Surgery, Disease, Attack) Yes No Psychiatric/Psychological Care Yes No

Heart Murmur Yes No Stomach Problems / Reflux / Heartburn Yes No

Hepatitis A (Infectious) B (serum) Yes No Ulcers (Diabetic) Yes No

Varicose Veins Yes No Leg Swelling Yes No

Leg Pain/Aching Yes No Leg Cramps Yes No

Heaviness in Legs Yes No Restless Legs Yes No

I understand the above medical information is necessary to provide me with medical care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any changes in my health or medication.

X / / Patient/Guardian Signature Date HISTORY REVIEWED BY: DR. SIGNATURE DATE Midwest Podiatry Services, a division of

(Please Print) REGISTRATION FORM Today’s Date / / Facility Doctor

PATIENT INFORMATION Patient’s Last Name First Middle Birth Date / / DEMOGRAPHICS (FOR GOVERNMENTAL STATISTICAL ANALYSIS)

Race American Indian or Alaska Native Asian Native Hawaiian Black or African American White Hispanic Other Pacific Islander Other Race I Decline to Report

Ethnicity Hispanic Non-Hispanic I Decline to Report

Preferred Language English Spanish Other PHARMACY / PRESCRIPTION INFORMATION

Preferred Pharmacy:

Costco CVS Osco Target Wal-Mart Walgreens Other

Address or Cross-Streets:

State:

Zip Code:

Phone Number:

Fax Number:

This is a mailorder pharmacy

I do not have a preferred pharmacy

I authorize Weil Foot & Ankle Institute and its affiliated providers to view my external prescription history via the Surescripts service. I understand that prescription history from multiple other unaffiliated medical providers, insurance companies, and pharmacy benefit managers may be viewable by my providers and staff here, and it may include prescriptions back in time for several years.

MY SIGNATURE CERTIFIES THAT I READ AND UNDERSTOOD THE SCOPE OF MY CONSENT AND THAT I AUTHORIZE THE ACCESS.

CONSENT TO OBTAIN EXTERNAL PRESCRIPTION HISTORY X / / To Weil Foot & Ankle Institute, Ltd. Signature Date Midwest Podiatry Services, Ltd. Appointment Policy

A Message to Our Patients:

Please note that due to the large number of missed appointments, our office has implemented a new policy.

If you are unable to keep your scheduled appointment, our office must be given 24 hours notice prior to your scheduled appointment, or your account will be billed $25.00.

Please sign below to indicate that you have read and understand our new appointment policy.

Thank you very much for your cooperation.

Midwest Podiatry Services, Ltd.

Patient Name

Patient Signature

Date Directions to Copley From The North: Take IL-59 S to N Eola Rd in Aurora Turn left onto N Eola Rd Turn right onto US-34 W At the stop light, turn right to enter the grounds of Rush-Copley, then turn right and follow the drive around until you reach the 2020 Professional building.

From the West: Head southeast on US-30 E Use the left 2 lanes to turn left onto US-30/US-34 Continue to follow US-34 At the stop light, turn left to enter the grounds of Rush-Copley, then turn right and follow the drive around until you reach the 2020 Professional building.

From the South: Head northwest on US-30 W to Aurora Township Turn right onto US-34 At the stop light, turn left to enter the grounds of Rush-Copley, then turn right and follow the drive around until you reach the 2020 Professional building.

Copley, 2020 Ogden Ave, Suite 400, Aurora 60504