Intake Form

 

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Patient Information

Today's Date

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Patient Address

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

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Person Responsible for Payment (if not Patient or minor)

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Local Pharmacy

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Mail Order Pharmacy

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Contact Person Other than Yourself

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Insurance Information

Primary Insurance

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Secondary Insurance

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Tertiary Insurance

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I attest that 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.
By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form.
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Medical History

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Review Of Systems

Please check all that apply to your current symptoms
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Family History - Indicate whether mother, father, or both. Please check all that apply.

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Social History

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I attest that 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 medical record only. They will not be published as part of medical research or disbursed in any way without my permission.
By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form.
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Step Alive Foot & Ankle Center, Dr. Thomas F. Vail, Notice of Privacy Practice and Office & Payment Policies.

Thank you for choosing Step alive Foot & Ankle Center as your foot care provider. We are committed to providing you with quality and affordable health care.

Please read the following office payment policy and feel free to ask us any questions that you may have. Once you accept this policy, kindly sign in the space provided. A copy will be provided to you upon request.

Insurance We participate in most insurance plans, including Medicare. If you are not insured by a plan we participate with, payment in full is expected at each visit. If you are insured by a plan we participate with but do not have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. For any insurance plan that requires authorization from a primary care physician (e.g. HMO, PPO, etc.) it is your responsibility (as patient or guardian) to be sure that this office receives all necessary referrals or authorizations PRIOR to treatment. A health insurance policy is a contract between you (the patient or subscriber) and your insurance carrier. You MUST notify this Office of any changes to your Insurance policy including policy termination, changes in co-payments or a new insurance policy. If for any reason the insurance carrier denies charges, payments for any services rendered will become the responsibility of the patient/guardian. Each policy has different deductibles, co-pays, and co-insurance responsibility of the participant. Therefore, we encourage you to check your policy’s specific requirements for precertification for various treatments that may be planned for specific care. This may include, but not be limited to, MRI, bone scans, and physical therapy. We will continue to pre-certify surgeries and precertify as well as check into orthotics coverage as needed. However, a quote of benefit coverage is not a guarantee of payment. This office is not responsible for services rendered and not covered. Please contact your insurance company with any questions you may have regarding your coverage.
Co-Payments and Deductibles All co-payments must be paid at the time of service. It is ultimately the insurance policy holder’s responsibility for any and all financial aspects of services rendered. This arrangement is part of your contract with your insurance company. Failure on our part to collect copayments from patients can be considered fraud. Please help us in upholding the law by paying your copayment at each visit. Deductibles are due immediately when insurance deems patient responsible. We reserve the right to ask for payment on deductibles not met before certain treatments and surgeries.
Non-Covered Services Please be aware that some – and perhaps all – of the services you receive may be uncovered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of visit. Medicare does not cover routine foot care; this includes the trimming of nails and cutting of calluses if you do not meet certain systemic conditions. Your doctor will determine if you qualify at your initial evaluation. If you are a diabetic or have peripheral vascular disease or painful nails, Medicare may pay for cutting of fungus nails. Medicare has other requirements such as timely appointments with your primary care physician or your specialist who manages your diabetes or peripheral vascular disease in order for these services to be covered. This would be your responsibility to supply those dates of service at your visit for your foot care. You also must be seen within the past 6 months by your primary care physician. Completion of FMLA, Short Term Disability, Insurance Forms, etc. are not covered by your insurance and payment is due upon submission.
Proof of Insurance All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your driver’s license and current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim. If required, obtaining the proper referral form from your Primary Care Physician is your responsibility. Patients presenting to our office without a valid referral will be asked to pay in full. This payment will be held for 48 hours and will become non refundable if the proper referral is not obtained by then.
Claims Submission We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claims. Your insurance benefit is a contract between you and your insurance company
Coverage Changes If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits.
In-Office Supplies Our office supplies as a convenience to our patients over-the-counter supplies. This is an effort to eliminate going to the store to pick these items up. In order to stock these supplies, we require payment at the time of service. Insurance companies do not cover the cost of these supplies; therefore you are responsible. The office assistant will discuss a fee for the item prior to your departure. If you are unable to pay for the item at the time of service, then we kindly request you return to pick up the item when you are able to afford it.
Nonpayment Invoices are sent out every 30 days. Your prompt payment will assist us in keeping the cost of healthcare down. A re-billing charge of $10.00 per month will accrue on all accounts 30 days past due and over. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to collection with an additional charge added to cover the cost of the collection agency service fee. If this occurs you and your immediate family members may be discharged from this practice. If this is to occur, you will be notified by regular and certified mail that you have 30 days to find alternative podiatric care. During that 30-day period, our physician will only be able to treat you on an emergency basis. Any checks returned with insufficient funds will be charged a processing fee.
Missed Appointments Our policy is to charge for missed or canceled appointments unless for understandable reason. These charges will be your responsibility and billed directly to you. Please help us to serve you better by keeping your regularly scheduled appointment.

Our fees are representative of the usual and customary charges for our area.

Thank you for understanding our payment policy. Please let us know if you have any questions or concerns.

I hereby give my permission for Dr. T.F. Vail, DPM to examine my feet medically or orthopedically. I authorize release of any information pertaining to my medical treatment.
The undersigned hereby authorizes the release of any information relating to all claims for benefits submitted on behalf of myself and/or dependents. I further expressly agree and acknowledge that my signature on this document authorizes my physician to submit claims for benefits, for services rendered or for services to be rendered, without obtaining my signature on each and every claim to be submitted for myself and/or dependents, and that I will be bound by this signature as though the undersigned had personally signed the particular claims.
I hereby authorize my insurance company to pay and hereby assign directly to Dr. Thomas F. Vail and the Step Alive Foot & Ankle Center (SAFAC) all professional and medical benefits through the means off electronic funds transfer(s) *EFT) or by check(s) made payable to and mailed to SAFAC, if any, otherwise payable to me for his services. I understand I am financially responsible for all charges incurred. I further acknowledge that any insurance benefits when received by and paid to Dr. Thomas F. Vail will be credited to my account, in accordance with the above said assignment.

Notice Of Privacy Practice Acknowledgment

I understand that, under the Health Insurance Portability & Accountability Act of 1998 (“HIPAA”), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
  • Conduct, plan and direct my treatment and follow up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
  • Obtain payment from third-party payers.
  • Conduct normal healthcare operations such as quality assessments and physician certifications.
I acknowledge that I have received your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.
I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.
I also authorize my health care provider and/or any entity authorized by my healthcare provider, including those using automated dialing systems, automated messages, email, text messaging or other electronic communication to contact me for any reason by using any telephone number, email address and/or mailing address provided.

I have read and understand the Notice of Privacy Practice (HIPAA), and Office & Payment Policies and agree to abide by its guidelines

By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form.
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Patient Easy Pay Policy and Consent

We will submit charges for your medical care directly to your insurer if we have a contract with that company.
All co-pays are due before your visit with the doctor. All over-the-counter products purchased through the clinic are due upon check-out at your visit.
Please be aware that balances deemed patient responsible, either due to deductible, co-insurance or a non-covered service, may become due prior to your next follow-up visit. We accept for your convenience MasterCard, Visa, and Discover.
In order to continually give the highest quality healthcare we ask that any balance remaining on charges after your insurance company pays their portion be charged to your credit card/or health savings card. As a courtesy, we will call you before processing any charges on your credit card above $50.00. The information will be kept secure and confidential. You will receive a receipt via email for any charges on your credit card or health savings card.
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Please type your Credit Card number or 0000 if you choose not to do 'Easy Pay'
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By typing your name bellow, you are signing this form elctronically. You agree your electronic signature is the legal equivalent of your manual signature on this form.
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