Step 1 - Fill Out Patient Information (Required for Visit)

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PATIENT INFORMATION

Patient Name
Legal Name
Patient's Address
Enter MM/DD/YYY
Can We Leave a Message?
Please tick all that apply
Responsible Party (if minor)
***This field is required if the patient is a minor. If this does not apply to you, please put in NA or None. ***
Responsible Party Address
***REQUIRED IF PATIENT IS A MINOR***
***REQUIRED IF PATIENT IS A MINOR***

MEANINGFUL USE:

For internal use only
For internal use only

INSURANCE INFORMATION - Please remember to bring your insurance card to your visit!

Required Field: if this does not apply then enter 123456789 or NA
Required Field: if this does not apply then enter 123456789 or NA
Required Field: if no policy put NA or MM/DD/YYYY of Patient DOB
If you hold a secondary insurance, please provide all additional information including: address, policy holder, relationship, group number, Id number, policy holder date of birth in the fields below.
Secondary Insurance Address (if applicable)
Enter MM/DD/YYYY

HEALTHCARE PROVIDER INFORMATION

Please add a contact phone number and email address
If no former Podiatrist type None
Please add a contact phone number and email address

ACCIDENT INFORMATION (If condition is not result of accident enter NA)

Use MM/DD/YY or if not result of an accident enter NA or None
If Not result of an accident enter NA or None
If this does not apply select No
If this does not apply select No
If this does not apply enter NA or None

FINAL STEPS

How Did You Hear About Us?

By signing this document:

  1. I hereby give my permission to administer treatment, and to perform such procedures as may be necessary in diagnosis and treatment.
  2. I will furnish insurance forms & information and I agree to pay my co-payment, deductible and non-covered portions at the time of my visit or when billed by the office.
  3. *Minors* I agree that I am the legal guardian of this patient, and understand that only the legal guardian is allowed in the exam room.
  4. I understand that a photograph may be taken of me for insurance verification purposes, and if I disagree with this process I will let the office know.

Signature Agreement

"By typing your name in the field below, you agree that this constitutes your electronic signature, valid as per applicable laws."
Enter MM/DD/YYYY

PATIENT FINANCIAL RESPONSIBILITY

Our Providers: Dr. Dan Bangart | Dr. Keith Bangart | Dr. Jeff Thomas | Dr. Shane Moore | Dr. Ryan Bangart | Dr. Austin Rollins

As a courtesy to our patients, we have enrolled in numerous managed care insurance programs. We are pleased to be able to provide this service to you, and we will make every effort to verify coverage and bill your insurance company correctly. However, it is not possible for us to keep track of all the individual requirements of each plan.

It is the responsibility of the patient to be aware of your insurance coverage, policy provisions, exclusions and limitations as well as authorization requirements. This information is furnished by your insurance carrier. Any charges that occur because of insurance plan restrictions is the patient's responsibility. Unfortunately, if you do not inform us of special requirements required by your plan and we order medically necessary service, such as lab work, x-rays, orthotics or supplies, not covered by your plan or should hit your deductible; we may bill you directly for those charges.

It is the responsibility of each patient to notify our office of any changes to their demographics and insurance coverage, and to know the details of his/her insurance plan. Any charges that occur because of lapses in coverage are ultimately the patient's responsibility. If current coverage cannot be verified, prior to each appointment, payment will be due at the time of service.

Payment of co-pay's are required prior to services being rendered. The patient will be responsible for any fees that are accrued due to any checks that are returned for nonpayment by the bank. Any patient responsibility that is not paid within 30 days from the date billed may be assessed a 2 1/2 % interest of the total amount due, per month. After 90 days of non-payment, your account will be subject to collections. You, as the patient, will be responsible for all collection charges.

Providing the highest quality of medical care for our patients is our primary concern. We are more than willing to provide the care within your insurance guidelines, whenever possible. With cooperation, you should be able to receive all the insurance benefits you are entitled to, and we will be able to focus our efforts on striving to provide you with excellent medical care.

By signing below, I acknowledge I have read and understand the following policies and I accept the rights and responsibilities with them:
ACKNOWLEDGMENT

I hereby authorize the physician to release any and all information necessary concerning my diagnosis and treatment for the purposes of securing payment from my insurance company and there by authorize payment of the insurance benefits directly to the physician for any services rendered that are not paid for directly by me.

PATIENT NAME