JOSEPH D. BROWN, D.P.M._______________________________________

PATIENT INFORMATION

NAME ____________________________DATE OF BIRTH ________________ AGE_________

STREET ADDRESS _______________________________________PHONE ___________________

CITY _____________________________________ STATE ____________ ZIP ________________

PATIENT EMPLOYED BY ________________________ OCCUPATION ________________________

BUSINESS ADDRESS ______________________________________ PHONE __________________

WHOM TO NOTIFY IN CASE OF EMERGENCY ____________________________________________
ADDRESS __________________________________________

PHONE ________________ WORK PHONE ________________

PATIENT’S MEDICAL INSURANCE ____________________________________________________

SOCIAL SECURITY NUMBER ______________________________

HEIGHT __________________ WEIGHT _______________ DO YOU SMOKE? _________________

DO YOU HAVE? DIABETES _____________ HYPERTENSION _______________

CANCER ______________ HEART DISEASE _______________

OTHER ____________________________________________

MEDICATIONS _________________________________________________________________

____________________________________________________________________________

WHAT IS YOURMAIN FOOT CONCERN? ________________________________________________

WHO IS YOUR PHYSICIAN? _________________________________________________________

HOW DID YOU HEAR ABOUT US? _____________________________________________________

I hereby authorize Joseph D. Brown, D.P.M., to release information to insurance companies and referred physicians concerning my medical treatments. I understand I am financially responsible for all charges.

I request that payment of authorized Medicare benefits be made either to me or on my behalf to Sedalia Foot Clinic, P.C. for any services furnished me by that physician/supplier. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable to related services.

I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. My signature authorizes releasing of the information to the secondary insurer or agency. In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and non-covered services. Coinsurance and a deductible are based upon the charge determination of the Medicare carrier.

Signature___________________________________ Date __________________

ACKNOWLEDGMENT OF RECEIPT

OF

NOTICE OF PRIVACY PRACTICES

I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read (or had the opportunity to read if I so choose) and understood the Notice.

_______________________________ ___________________

Patient Name (please print) Date

_______________________________

Parent or Authorized Representative (if applicable)

_______________________________

Signature