Intake Form


Please complete the following form and answer all questions before arriving for your appointment.

Be sure to include your insurance information.
We'll see you soon!

Patient Information

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Sex
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Race




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

Ethnicity
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Preferred Language
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Are you pregnant?
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Are you nursing?
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Have you completed an Advance Directive (living will)?
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Who referred you to our office?




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Is it limiting your activity level?
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Medical History (please check all that apply)
































































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Is your problem related to a Workman’s Comp injury or an auto/other accident?
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Social History

Do you drink alcohol?
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How often?
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Do you smoke, vape or use chewing tobacco?
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Please specify
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Do you have/have had a substance abuse problem?
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Family History

Which family members had the below medical conditions? (father, mother, sibling, etc.)

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Insurance Information

Do you have insurance
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HMO
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Emergency Contact

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Responsible Party (if minor patient)

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View Privacy Policy

Consent for Treatment and Acknowledgement of Policies

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. Professional services are rendered and billed directly to your insurance carrier; however you, the patient/guardian, are directly responsible for services rendered by the doctor. 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.
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All office visit charges and co-pays are due at the time services are rendered. It is the patient who is responsible for any and all financial aspects of services rendered. There will be a charge for returned checks, missed appointments without 24 hours notice and completion of any forms. I agree to pay for all deductibles, co-pays, non-covered services and any portion of covered services not paid in full by my insurance plan and understand that such payments are due at the time of service or immediately upon presentation of the bill. I hereby name Arch Advantage Foot & Ankle Center (AAFAC) as my assignee. I instruct my health care benefits plan administrator, i.e. PLAN to pay AAFAC directly for all professional and medical services provided by AAFAC through the means of electronic funds transfer(s) (EFT) or by check(s) made payable to and mailed to AAFAC. I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS CLAIMS.
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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 my medical record only. They will not be published as part of medical research or disbursed in any way without my permission.
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I acknowledge that I was provided a copy of the Notice of Privacy Practices for Arch Advantage Foot & Ankle Center and I have read (or had the opportunity to read if I so choose) and understood the Notice.
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PAYMENT RESPONSIBILITIES

Your insurance policy is a contract that exists between you and our insurance company. Our relationship is with you, the patient, and not the insurance company. If you have questions about your policy, please call the phone number provided on the back of your insurance card. The patient or responsible party is responsible for their bill being paid in full. Please inform us at every visit of any changes to your insurance coverage.

COPAYMENTS: It is a requirement of your insurance company that we collect your co-pay. Payment is required before meeting with the doctor.

DEDUCTIBLES & COINSURANCE: If you have a high deductible plan, we may collect a $125 deposit to apply towards your deductible and coinsurance. Any remaining balance after submission to your insurance company is your responsibility.

SELF- PAY: (for non-covered products and services and for patients without insurance coverage): Full payment is due at the time of service. A down-payment will be required before seeing the doctor. At a minimum, an evaluation and management fee will be charged. Additional procedures/services may be recommended by the doctor. You will be informed of these charges before proceeding with treatment.

REFERRAL: If your insurance plan requires a referral from your primary care doctor, this will be required at the time of your visit. Without a referral available, we may need to reschedule your appointment.

NO SHOW: (failure to present for your appointment): 24 hours notice is required for cancellation of your appointment and failure to do so will incur a $100 fee.

SURGERY CANCELLATION: Failure to provide 5 business days notice before surgery will incur a $450 fee.

BALANCES/COLLECTION FEES: If payment of an outstanding balance is not received within 30 days from the post mark date of a mailed statement or e-statement time stamp, a $10 rebilling fee may be added to each additional statement. Our patient portal offers the ability to view statements and submit payments conveniently and securely. Patients with balances more than 90 days overdue will be turned over to collections and a $35 administrative fee will be applied.

RETURN CHECK FEE: A $35 fee will be assessed for all returned checks.

FMLA/DISABILITY/MEDICAL RECORDS: There is a $30 charge for having the doctor complete these forms. Requested forms will be completed within 5-7 business days of diagnosis and care plan. The same $30 fee will be incurred to obtain a copy of your medical records.

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Advanced Podiatric Procedures & Services in the Marion County, IN: Indianapolis, Lawrence, Beech Grove, Speedway, Southport, Pike Township, Warren Township, Franklin Township, Hendricks County, IN: Brownsburg, Avon, Plainfield, Danville, Hamilton County, IN: Carmel, Fishers, Noblesville, Westfield, Noblesville, Johnson County, IN: Greenwood, Franklin, Whiteland, Bargersville, Morgan County, IN: Mooresville, Martinsville areas
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