Thank you for choosing our office. In order to serve you properly, we will need the following information. All information will be kept confidential. As a new patient you will be given a HIPPA information sheet to review and sign. It lets you know specifically how your personal health information will and will not be used. If you have any questions or would like a copy, please notify the front desk.
You may complete the Patient Information Sheet and bring it with you to your first appointment or complete this form at your initial visit.
You must print the Patient Information Sheet (it cannot be completed on line)
HIGHLIGHT AND PRINT SCREEN. WHEN COMPLETING THIS FORM. PLEASE PRINT AND USE A BLACK INK PEN. Thank You.
Letting your Dr. know what medications, supplements (prescription and over the counter) is important. Too often, patients tell doctors they don't remember the name or prescribed dosage of their medications. "I think I stopped taking the pink, tiny pill, but I'm still taking the white one and the blue one,". Remember to bring an updated, accurate list to your appointmen
A. Michael Marasco, DPM, FACFAS 420 E. 86th Avenue Merrillville, IN 46410
Date ____________________ Referred By _________________________
Patient Name __________________________________________________
Spouse or Parent's Name ________________________________________
SSN ________________________ Male _____ Female _____ Birth date ____________________________ Minor ___ Single ___ Married ___ Other ____
Race ___________________ Ethnicity: Not Hispanic, Latino, or Spanish Origin _____________
Preferred Language ______________________
Address ________________________________________________________________________________________ Street City State Zip Code
Home Phone __________________________________________________
Patient's Employer _______________________________________________ Work Phone _________________________
Person to Contact in Case of an Emergency _________________________________ Phone __________________________
Responsible Party Name of Person Responsible for this Account ______________________________
Relationship to Patient ______________ Address _____________________________________________________________________________________________ Street City State Zip Code
Phone Number __________________________
You will need to present your insurance card and a photo ID (Driver's License) at your appointment.
Primary Insurance Information Name of Insured _____________________________________________________ Relationship to Patient _______________ Name of Insurance Company ___________________________________________
Secondary Insurance Information Name of Insured _____________________________________________________ Relationship to Patient _______________ Name of Insurance Company ___________________________________________
I authorize my insurance benefits to be paid directly to the physician and I understand that I am financially responsible for any and all copayments, co-insurance, deductibles and non covered services. I understand that some services may be denied by certain insurance plans due to medical necessity and I agree to be financially responsible for these services. Payments are due upon receipt of statement. Accounts not paid within 30 days will be considered Past Due and subject to a $5.00 rebilling fee. Accounts 90 days Past Due are considered Delinquent. If it becomes necessary to employ a collection agency, service or attorney to enforce payment, you will be responsible for the costs and fees charged for such services.
I authorize thephysician to release any information necessary to process claims for insurance benefits. I understand that honest and complete answers to questions stated are important to the provision of my medical care and I have answered them to the best of my ability. I have been informed that if I am uncertain about any questions on the Patient Information Sheet or Health Questionnaire I should ask the Doctor or a member of the office staff for assistance.
____________________________________________________________________________________________________ Signature of Patient/Legally Responsible Adult Date
You will also need to bring a complete and current list of your medications and dosages and the name and address of your pharmacy so that we may have accurate and up to date information for your Electronic Medical Record (EHR) as required and directed by the Obama Healthcare Act - American Recovery and Reinvestment Act (ARRA).