Thank you
for choosing us as your Foot and Ankle Specialist!
Instructions:
Please click on the form names to access the document. You can then fill-in the requested information, print the form and bring with you to your appointment.
Files are in Abobe Reader format. If you do not have Adobe, please click here to download your free copy.
New Patient Forms:
Patient Registration Packet - Includes your registration, Notice of Privacy Practice and Payment Policy. Please complete this form and bring with you to your appointment. (Please view our HIPAA Privacy Practice before signing the acknowledgement form.)
Patient History Form - Please complete this form and bring with you to your appointment
*Please remember to bring a valid photo ID and your insurance cards.
HIPAA Forms:
Notice of Privacy Practices - Our HIPAA policy.
Right to Inspect Form - You may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information.
Request of Restrictions Form - You may request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in the Notice of Privacy Practices.
Health Record Amendment Form- You may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment
Complaint Form - If you believe your privacy rights have been violated, you can file a complaint using this form.
Patient Satisfaction Survey - We welcome all patients to fill out this quick survey after any visit. We hold monthly drawings of all those submissions for a prize.
PADNet Survey- All patients are welcome to fill out this survey to see if they are at risk for PAD.
CVI Survey- All patients are welcome to fill out this survey to see if they are at risk for venous insufficiency.
