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  1. 1. METROPOLITAN FOOT & ANKLE SPECIALISTS<br />Thomas J. Savage, DPM Michael B. Stern, DPM<br />Medical Center of Aurora, North<br />830 Potomac Circle, Suite #340<br />Aurora, Colorado 80011<br />(303)366-8191 (303)341-0694 fax<br />Please print and complete all parts. Date_______________<br />PATIENT INFORMATION<br />Name_______________________________________________ Sex Male___ Female___<br />Address_____________________________________________ Apt.#__________________<br />City____________________ State________ Zip _______ Social Security#_______________<br />Home Phone___________________ Work_________________ Cell_____________________<br />Date of Birth___/___/___ Age____ Single__ Married__ Widowed__ Divorced__<br />Referred by________________________ Former Podiatrist____________________________<br />Primary Care Physician___________________________ Last Seen_______________________<br />Employer_________________ Occupation____________ Work Injury? Y__ N__ Date___<br />Chief Complaint/Reason for visit___________________________________________________<br />INSURANCE INFORMATION (We will need a copy of your insurance cards.)<br />Primary Insurance________________________ ID/Policy # ___________________________<br />Subscriber___________________________ Group#_____________ Copay $_____________<br />Relation to Subcriber: Self__ Spouse__ Child__<br />Deductible Amount_________________________ Deductible Amount Met_______________<br />Secondary Insurance______________________ ID/Policy #_____________________________<br />Subscriber___________________________ Group#__________ Deductible/Copay_________<br />Assignment of benefits: I Authorize payment of medical benefits to Dr. Thomas J Savage or Dr. Michael B <br />Stern for service provided to me. I authorize release of any medical information necessary to process this <br />and all future claims. I understand that I, not the insurance, am the responsible party for all fees incurred. <br />X<br /> Signature Date<br />MEDICAL INFORMATION<br />DO YOU HAVE ANY OF THE FOLLOWING? (Check Yes or No, or write in)<br />MEDICAL HISTORY<br />DIABETES ________________________________HIV+_________________________________<br />GOUT ________________________________HEART DISEASE _________________________________<br />EPILEPSY ________________________________HIGH OR LOW BLOOD PRESSURE ____________________<br />PARKINSON’S ________________________________ANGINA _________________________________<br />CANCER ________________________________HEART MURMUR _________________________________<br />HEPATITIS ________________________________ASTHMA _________________________________<br />THYROID DISEASE ________________________________EMPHYSEMA _________________________________<br />SKIN DISORDERS ________________________________BLOOD CLOTS _________________________________<br />STOMACH ULCERS ________________________________KIDNEY DISEASE _________________________________<br />POOR CIRCULATION ________________________________NEUROPATHY _________________________________<br />PRESENT MEDICATIONS<br />ALLERGIES (I.E. Aspirin, Penicillin, Codeine, Iodine, Adhesive tape, Local Anesthetics, etc.)<br />SOCIAL<br />Y___ N___ EmployedY___ N___ SmokeY___ N___ AlcoholY___ N___ Drug Use<br />REVIEW OF SYSTEMS<br />HEART/CIRCULATION RESPIRATORY<br />Y___ N___ PalpitationsY___ N___ Shortness of Breath<br />Y___ N___ Chest PainY___ N___ Cough of Wheezing<br />Y___ N___ Leg SwellingY___ N___ Tuberculosis<br />Y___ N___ Leg cramps/pain on walkingY___ N___ Pulmonary Embolism<br />Y___ N___ Past Heart Attach/Bypass<br />DIGESTIVEURINARY<br />Y___ N___ Weight gain/LossY___ N___ Frequent urination<br />Y___ N___ History of UlcersY___ N___ Burning<br />Y___ N___ Blood in stool Y___ N___ Blood in urine<br />Y___ N___ Diarrhea / Constipation Y___ N___ Frequent Urinary infections<br />Y___ N___ Stomach pain or cramps<br />____________________________________________________________________________________________________________________________________________________________________________________<br />NEUROLOGICAL PSYCHOSOCIAL<br />Y___ N___ HeadachesY___ N___ Anxiety<br />Y___ N___ Seizures/ConvulsionsY___ N___ Depression<br />Y___ N___ Tingling/burning/painY___ N___ RSD (reflex sympathetic dystrophy)<br />Y___ N___ Neuropathy (loss of feeling)<br />SKINEYES/EARS/NOSE/MOUTH<br />Y___ N___ Itching/burningY___ N___ Visual changes<br />Y___ N___ DiscolorationY___ N___ Hearing difficulties<br />Y___ N___ New spots/Ulcerations/WoundsY___ N___ Sinus or mouth problems<br />MUSCLES, JOINTS, BONES BLOOD<br />Y___ N___ ArthritisY___ N___ Bleeding disorders<br />Y___ N___ Osteoporosis Y___ N___ Anemia<br />FAMILY HISTORY (I.E. Diabetes, Heart, Cancer, Foot Problems, etc.)<br />PAST SURGICAL HISTORY (List type of surgery, when, any complications)<br />ANY OTHER INFORMATION YOU THINK WE SHOULD KNOW?<br />THANK YOU FOR TAKING THE TIME TO ACCURATELY COMPLETE THIS INFORMATION.<br />METROPOLITAN FOOT & ANKLE SPECIALISTS<br />830 Potomac Circle, #340<br />Aurora, CO 80011<br />(303)366-8191<br />Office Financial Policy Name: <br />Payment will be expected at the time of service for all non-contracted fees and copayments. Our office accepts cash, personal checks, MasterCard/ Visa/Discover credit or debit cards, and participates with most insurance plans. <br />Insurance Participation: We will accept assignment on all covered services and bill your insurance carrier for you. You are responsible for all copayments, coinsurance, and deductibles, and for all non-covered services provided. You are responsible for obtaining any referrals if required.<br />We will do our best to help you obtain benefits, but we cannot be responsible if your insurance does not pay or process your claim within a reasonable time (90 days from date of service). Further, if a member of our staff advises you that you are fully covered or implies that you will owe nothing, it is your responsibility to contact your insurance company for verification. Therefore, it is your responsibility to make certain your insurance carrier provides prompt payment and to handle any disputes that may arise. You are ultimately the financial party responsible for all services provided regardless of insurance.<br />It is your responsibility to provide us with the correct, up to date insurance information, including a copy of the most recent insurance identification card. We can only bill your insurance with this information. At your request, a secondary insurance will be billed as a courtesy, for one time only. <br />If your insurance is found not to be in effect on the date of services provided, you will be responsible for the full balance with no discounts. A finance charge of 18 percent APR (1.5% per month) will be added to the total balance on all accounts over 90 days past due. <br />If at any time you have questions regarding any treatment, fees, or services, please discuss them with us promptly and frankly. We will make every effort to avoid a misunderstanding, to rectify an injustice, or to preserve a friendship. <br />Missed Appointments: Our policy is to charge for missed appointments unless a cancellation is received at least twenty-four hours in advanced. The charge is $50.<br />Treatment of Children: Our office welcomes treatment for all patients, including children! All children 17 years of age and under, scheduled for treatment, must have a parent or legal guardian present in the office during their appointment or have provided written/oral consent for each visit.<br />Cellular Phones/Pagers: We request all cellular phones and pagers be turned off or to silent mode during your appointment.<br />Family/Friends: for the safety, comfort and privacy of our patients and employees, no friends or family members will be permitted to accompany a patient in the treatment room during the appointment unless previous authorization with the patient and physician have been obtained. Any patient with special needs can make necessary arrangements with our office prior to your appointment.<br />We reserve the right to dismiss any patient from our practice for inappropriate behavior in our office or on the phone.<br />I acknowledge that I am responsible to pay all charges for services provided by Dr. Thomas J. Savage’s or Dr. Michael B. Stern’s office as outlined above and that if my account is placed with a collection agency for non-payment that I will be responsible for all collection costs, including court costs and associated attorney fees.<br />I have read the policies and agree with the terms outlined above. A copy of this signed agreement has been provided.<br />Responsible Party Signature: ___________________________________ Date:_____________<br />