Intake Form

Please complete the following form and answer all questions before arriving for your appointment.
Our office will have a printed copy of your form so please do not print it as well.

Be sure to include your insurance information. We'll see you soon!

Patient Information

First name (*)

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Middle Initial

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Last name (*)

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Your Email Address (Responsible Party) (*)

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Mailing Address (*)

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City (*)

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State (*)

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Zip-Code (*)

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Phone number (*)

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Date of Birth: Month (*)

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Day (*)

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Year (*)

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Sex (*)

Male Female

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Marital Status (*)

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Height (*)

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Weight (*)

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Shoe size (*)

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Race(*)

*This information is requested due to Healthcare Reform laws dictated by Congress.

Ethnicity

Hispanic or Latino Non-Hispanic or Non-Latino Decline to Specify Invalid Input

Are you pregnant?(*)

No Yes Invalid Input

Are you nursing?(*)

No Yes Invalid Input

Primary Care Physician (*)

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Primary Care Physician Address (*)

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Physician Phone Number (*)

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Date last seen: Month

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Day

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Year

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Pharmacy (*)

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Pharmacy Phone (*)

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Who?

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Other

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Primary Reason for Visit (*)

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Duration of Condition (*)

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What helps / makes it worse?

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Is it limiting your activity level? (*)

Yes No

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Secondary problem (if there is one)

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Please list any drug allergies (*)

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List Medications You Take (*)

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Specify other

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If you have cancer, please list type and treatment

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Please list past surgeries and year surgery was performed (*)

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Is your problem related to a Workman’s Comp injury or an auto/other accident?(*)

No Yes

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We’re sorry we do not treat problems related to Workmen’s comp or accident cases. Unfortunately, you will have to seek care elsewhere.

Do you drink alcohol?(*)

Never Past Yes

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How often?

Daily 1-2 x Week 1-2 x Month 1-2 x Year Invalid Input

Do you smoke, vape or use chewing tobacco?(*)

Never Past Yes

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Please specify

Cigarettes Cigars Chewing Tobacco Vaping Invalid Input

How many per day?

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Method of Quitting

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Do you have/have had a substance abuse problem?(*)

Never Past Yes

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Please specify

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Family History

Which family members had the below medical conditions? (father, mother, sibling, etc.)

Diabetes

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Stroke

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Cancer

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Arthritis

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Heart Attack

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HTN

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Other

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Insurance Information

Subscriber's Name (*)

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Subscriber's D.O.B. (*)

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Patient's Relation to the Subscriber (*)

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HMO (*)

Yes No

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Primary Insurance (*)

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Policy Number (*)

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Policy Holder Name (*)

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Policy Holder Date of Birth: Month (*)

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Day (*)

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Year (*)

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Secondary Insurance

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Secondary Policy Number

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Occupation (*)

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Employer (*)

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Employer Address

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City

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State

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Zip-Code

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Employer Phone Number

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Emergency Contact

First Name (*)

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Last Name (*)

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Relationship to Patient (*)

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Phone (*)

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Responsible Party (if minor patient)

First Name

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Last Name

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Relationship to Patient

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Date of Birth: Month

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Day

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Year

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All office visit charges and co-pays are due at the time services are rendered. It is the patient themselves whom are responsible for their financial aspects of services rendered. There will be a charge for returned checks, missed appointments without 24 hours notice and completion of any forms (see the paragraph below for more details). I agree to pay for all deductibles, co-pays, non-covered services and any portion of covered services not paid in full by my insurance plan and understand that such payments are due at the time of service or immediately upon presentation of the bill. I hereby name Summit Podiatry (SP) as my assignee. I Instruct my health care benefits plan administrator, i.e. PLAN to pay SP directly for all professional and medical services provided by SP. through the means of electronic funds transfer(s} (EFT} or by check(s) made payable to and mailed to SP. I AUTHORIZE THE RELEASE IF ANY MEDICAL INFORMATION NECESSARY TO PROCESS CLAIMS.

I Agree (*)

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NO SHOW/CANCELATIONS/SERVICE FEES: There will be a $25.00 service fee for all forms that need to be filled out by InStride Summit Podiatry (including short term disability, FMLA, work forms, etc), payment is due upon receipt of the forms, you must allow 5-7 business days for completion of the forms. There will be a $50.00 service fee for any appointment canceled in less then 24 hours’ or any missed appointments without prior communication to InStride Summit Podiatry (NO SHOW). Same day cancellations are considered a cancelation with less then 24 hours notice and will be charged as such. Failure to cancel, reschedule an appointment with a 24 hour notice, or failure to show up will result in a $50.00 no show fee that must be paid before scheduling another appointment.

I Agree (*)

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The above information is correct to the best of my knowledge. I understand that throughout my treatment, I am responsible for notifying the physician and/or medical staff of any and all updates to the information listed above. • I also give permission for photographs of my feet to be taken that are to be kept as part of my medical record only. They will not be published as part of medical research or disbursed in any way without my permission.

I Agree (*)

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Authorization for Release of Health Information

Please Check Information to Be Released and Specific Date of Service if Applicable:

Date From: Month

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Day

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Year

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Date To: Month

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Day

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Year

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Pertaining to:

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I authorize InStride Summit Podiatry to release and/or obtain the requested health information to/from:

Name/Organization:

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Address:

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City

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State

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Zip-Code

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Phone

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Fax

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Check the Preferred Method for Releasing the Requested Information:

I will pick up
I will have some one pick up for me
Fax to the number provided above (only for release to healthcare providers) Invalid Input

Spouse
Parent/Guardian
Child
Other Invalid Input

Other

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FEES: Medical Record copies will be provided to you at a fee of $15.00 per request (plus postage if mailing). Digital X-Ray copies will be provided to you on a CD for a fee $10.00 per request (plus postage if mailing).
I understand that if the person or entity that receives this information is not a healthcare provider or health plan covered by federal privacy regulations, the released information may be re-disclosed by the recipient and may no longer be protected by federal or state law. I understand that I may revoke this authorization at any time by notifying InStride Summit Podiatry and completing a revocation of personal representative form. However, if I chose to do so, I understand that my revocation will not affect any actions taken by InStride Summit Podiatry before receiving my revocation. I understand that I may refuse to sign this authorization, and that my refusal to sign in no way affects my treatment, payment, enrollment in a health plan, or eligibility for benefits.

I acknowledge that I was provided a copy of the Authorization for Release of Health Information notice above and I have read (or had the opportunity to read if I so choose) and understood the notice.

Welcome to our New Patients

Welcome to our practice! We appreciate the opportunity to be of service to you and hope that you will be pleased with our services. Our practice is a division of the InStride Foot & Ankle Specialists, PLLC. We have divisions across North and South Carolina, and we operate under one tax id number. As such, if you have seen any of the following physicians in the past three years, we need to know so that we will not file a new patient code for your visit today. Since the insurance carriers look at us as one large practice, if you have been seen at any of the following divisions, you will not be considered a new patient in our practice. Visits prior to 2013 do not need to be disclosed.
Please review the names of the divisions and podiatrists below and indicate if you have been seen at any of these divisions by putting a √ on the line to the left of the practice name. Thank you for disclosing this information to us – it will allow us to be in compliance with nationally mandated correct coding initiatives.

I attest that I have been seen in the above indicated division of the InStride since 01/01/2013.
I attest that to my best recollection, I have not been seen by any of the above divisions/physicians since 01/01/2013.

PAYMENT RESPONSIBILITIES

We are pleased to welcome you to our office. New Patients are always appreciated. Our practice has grown as a result of its excellent relationship with our referring doctors and patients. As our patient, please feel free, at any time, to express any concerns or to ask any questions that you may have for the doctor or our staff. In order to assist you in making payment(s) for your podiatric treatment, the following options are listed. Please read them carefully and feel free to discuss them with us.

If you DO NOT have insurance: Payment is due, in full, at the time treatment is provided.

*For your convenience, we accept all major credit/debit cards and cash. We accept personal checks for payments under $50.00.

If you have Insurance: The percentage of coverage by your insurance company may be based on your insurance company’s own reduced fee schedule for medical services and may be less than actual charges resulting in lower coverage for you. Summit Podiatry has no control over this situation. Lower payment is a direct result of the plan selected by you or your employer. Please be advised that we cannot waive co-payment. We are required by law to collect co-payment.

Commercial Insurance: We will submit your claim to your insurance carrier for you. You are responsible for any deductible or co-payment not covered by your insurance. Once our office has received payment from the insurance company, you will be billed, with 30 day terms, for any amount still owed. You may choose to keep a credit card on file for those balances left to you by your insurance company.

Medicare: This office accepts Medicare assignment. Medicare patients are fully responsible, however, for the initial yearly deductible and the 20% co-insurance. Federal law requires that physicians collect this amount. If you have a secondary insurance to cover the 20%, we will submit the balance to that insurance for payment and you will only be responsible for the yearly deductible.

Please sign with your initials (*)

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Please ensure you have completed all mandatory fields on this form (indicated with an (*) asterisk next to the field) and please wait until our thank you page loads to ensure the form was successfully submitted otherwise your data will be lost.

Intake Form

Patient Information

Social History

Family History

Insurance Information

Emergency Contact

Responsible Party (if minor patient)

Consent for Treatment and Acknowledgement of Policies

Authorization for Release of Health Information

Welcome to our New Patients

PAYMENT RESPONSIBILITIES

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