PATIENT INFORMATION

Sex

Marital Status (please select)

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Primary Language (please select)

Financial Agreement

Please remember insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowance for certain procedures, and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance.

I request that payment of authorized insurance benefits be made on my behalf for any services furnished to me, I authorize any holder of medical information about me to be released to the health care financial administration: any information needed to determine these benefits or the benefits payable for related services.

I understand that  I am financially responsible for all charges whether or not paid for by said insurance. If payment is not made, balance will be forwarded to a collection agency.

I agree to reimburse fees of any collection agency, which may be based on a percentage at a maximum of 50% of the debt, insufficient funds fees of $35.00, and all costs and expenses, including reasonable attorneys' fees we incur in such collection efforts.

The assignment will remain in effect until revoked by me in writing, A photocopy of this assignment will be considered as an original. I hereby release all information necessary to secure the payment

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I,  _____________________________ acknowledge that I have received a copy of Dr. Jordan Sheff's Notice of Privacy Practices.  The notice describes how Dr. Sheff may use and disclose my protected health information, certain restrictions to the use and disclosure of my healthcare information and rights I may have regarding my protected health information.

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY

We are by applicable federal and state law to maintain the privacy of your health information.  We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information.  We must follow the privacy practices that are described in this Notice while it is in effect.  This Notice takes effect April 14, 2003, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law.  We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes.  Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time.  For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

USES AND DISCLOSURES OF HEALTH INFORMATION

We use and disclose health information about you for treatment, payment, and healthcare operations.  For example:

Treatment:   We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment:  We may use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations.  Healthcare operations include quality assessments and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certifications, licensing or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information to disclose it to anyone for any purpose.  If you give us an authorization, you make revoke it in writing at any time.  Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect.  Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice.  We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death.  If you are present, then prior to the use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosure.  In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgement disclosing only health information that is directly relevant to the person’s involvement in your healthcare.  We will also use our professional judgement and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Required by Law: We may use or disclose your health information when we are required to do so by law.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes.  We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances.  We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities.  We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders:  We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards or letters).

Access:   You have the right to look at or get copies of your health information, with limited exceptions.  You may request that we provide copies in a format other than photocopies.  We will use the format you request unless we cannot practically do so.  (You must make a request in writing to obtain access to your health information.  You may obtain a form to request access by using the contact information listed at the end of this Notice.  We will charge you a reasonable cost-based fee for expenses such as copies and staff time.  You may also request access by sending us a letter to the address at the end of this Notice.  If you request copies, we will charge you $0.25 for each page, $15.00 per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you.  If you request an alternative format, we will charge you a cost-based fee for providing your health information in that format.  If you prefer, we will prepare a summary or an explanation of your health information for a fee.  Contact us using the information listed at the end of this Notice for a full explanation of our fee structure).

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003.  If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to the additional requests.

Restriction:  You have the right to request that we place additional restrictions on our use and disclosure of your health information.  We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations.  (You must make your request in writing).  Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment:   You have the right to request that we amend your health information.  (Your request must be in writing, and it must explain why the information should be amended).  We may deny your request under certain circumstances.

Electronic Notice: If you receive this Notice via electronic mail (e-mail), you are entitled to receive this Notice in written form.

QUESTIONS AND COMPLAINTS

If you want information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use of disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice.  You also may submit a written complaint to the US Department of Health and Human Services.  We will provide you with the address to file your complaint with the US Department of Health and Human Services upon request.

We support your right to the privacy of your health information.  We will not retaliate in any way if you choose to file a complaint with us or with the US Department of Health and Human Services.

Contact Officer:   R. Keron Lazar

Telephone:   (401) 846-8050

Fax:   (401) 848-0458

Address:  392 Broadway Newport, Rhode Island 02840

MEDICAL HISTORY

Please bring your proof of vaccination card with you to your appointment.

INSURANCE CLAIMS PROCESSING DISCLAIMER

AND CONSENT FOR TREATMENT

1. By signing below, I certify that the above information, to the best of my knowledge, is true and correct.

2. I authorize the release of any medical or other information necessary to process my insurance claim.  I also authorize payment of medical benefits to Dr. Jordan S. Sheff for any services rendered.  In order to more smoothly and efficiently process third party insurance claims, I hereby give permission to release my insurance information.  Such information is only to be released for the purpose of filing health insurance claims to insurance companies and related agencies.  

3. By signing below, I also understand that although I may participate in a health insurance plan, that I am wholly responsible for payment of services rendered if my insurance carrier fails to pay for all or a part of services rendered.

4. I hereby give my permission to Dr. Jordan S. Sheff to examine and perform such procedures as may be deemed necessary by him and myself in the diagnosis and care for my foot condition.

INSURANCE INFORMATION

Individual Responsible for Payment (If Other than Patient)

Sex

Primary Insurance Company

Secondary Insurance Company

Newport Family Foot Care’s Appointment Cancellation / Late Arrivals / No Show Policy

Patient acknowledgment document

When you schedule an appointment with us, we set aside enough time to provide you with the highest quality care. If you need to cancel or reschedule an appointment, we would appreciate the courtesy of a call to our office as soon as possible, and no later than 24 hours prior to your scheduled appointment. Failure to do so may prevent another patient from getting much needed treatment. Please refer to our Appointment Cancellation/Late Arrival and No-Show Policy outlined below:

•  Any established patient who fails to show or cancels/reschedules an appointment and has not contacted our office with at least 24 hours notice will be considered a No Show and charged a $25 fee.
•  Any established patient who fails to show or cancels/reschedules an appointment with no 24 hour notice the second time will be charged a $50 fee.
• If a third No Show or cancellation/reschedule without 24 hours notice should occur, the patient may be dismissed from the practice.
•  Any new patient that fails to show for their initial visit may be dismissed from the practice.

We realize that delays can happen, however we try to keep the other patients and doctor on time. If you are running late, please notify the office. Depending on the day’s schedule we may have to reschedule your appointment.

We understand there may be times when an unforeseen emergency occurs including obligations for work or family that may prevent you from keeping your scheduled appointment. In the event of an actual emergency and prior notice could not be given, consideration will be given and a one-time exception may be granted.

If you call after business hours, please leave a message and we will contact you promptly.

You can reach the office 24 hours a day, 7 days a week at (401) 846-8050.

I have read and understand Newport Family Foot Care’s Policy and agree to its terms.

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