Adriana Strimbu, DPM, PA
                         404 N. Federal Hwy, Hallandale, FL 33009, Ph. (954) 455-9404, Fax (954) 455-9407
                                              www.hallandalebeachfootdoctor.com

PATIENT INFORMATION
Name:___________________________________________________________________Date:_____/______/_________                                                            		First name				Last name
Address:___________________________________________________________________________________________
City:_____________________________________________________State:______________Zip:____________________
Preferred Phone Number*:(_______)____________________Other Phone Number: (_______)______________________
*Appointment confirmation calls will always be made to the preferred phone number and a message with your appointment details will be left.*
Birthday: ______/______/_________   Age: ___________	SS# _________________________________________
Occupation: ______________________________   Marital Status:    ⃝ S     ⃝ M    ⃝ D     ⃝ W
E-mail: ___________________________________________________________________________________________
Primary Language:    ⃝ English     ⃝ Spanish     ⃝ Russian     ⃝ Other: ______________________________________
Ethnicity:     ⃝ Hispanic/Latino         ⃝ Non-Hispanic/non-Latino
Race:    ⃝ American Indian/Alaska Native      ⃝ Asian     ⃝ Black/African American      ⃝ Hawaiian/Pacific Islander      ⃝ White
Referred by: ____________________________________________________________________________________
Primary Care Physician:_____________________________________ Ph: (_______) ___________________________
Date of the last visit to your doctor:__________________________________________
Which Pharmacy do you use:_________________________________________________________________________
Address:__________________________________________________________________________________________
City:________________________________State:__________Zip:__________Ph:(______) _______________________

MEDICAL INSURANCE
Insurance's Name: ____________________________________   ID #: ______________________________________________
Secondary Insurance: __________________________________   ID#_______________________________________________

Adriana Strimbu, DPM, PA
                     404 N. Federal Hwy, Hallandale, FL 33009, Ph. (954) 455-9404, Fax (954) 455-9407
                                           www.hallandalebeachfootdoctor.com

MEDICAL HISTORY
Reason for Visit: ___________________________________________________________________________________
Shoe Size: _____________     Height: ____________    Weight: ______________    	
Are you 50 years or older?								_____ Yes _____ No
Have you ever been diagnosed with any of the following? (circle all that apply)
 Diabetes	Chronic Kidney Disease   High Blood Pressure    High Cholesterol					
Do you have foot, calf, buttock, hip or thigh discomfort (aching, fatigue, tingling, cramping or pain) when you walk which is relieved by rest?                                                     	_____ Yes _____ No
Do your toes or feet look pale, discolored or bluish?					_____ Yes _____ No
Do you have pain in the legs and/or feet, or legs that heal slowly or not at all?	_____ Yes _____ No
Does one leg or foot feels colder than the other one?					_____ Yes _____ No
Has your doctor ever told you that you have diminished or absent foot pulses?      ______Yes _____No
Poor nail growth and decreased hair growth over time on toes and legs?	        _____ Yes _____ No
Have you ever worn custom made arch supports (orthotics)?                       _____Yes ______No
Do you smoke you smoke?							        _____ Yes _____ No
if Yes, when did you start: _____________	How much? ________________
If No, did you ever smoke? _____Yes _____No  if Yes, when did you start: ___________ and stopped: _____________
Do you drink alcohol?  _____ Yes   _____ No 	if Yes, how much: _____________________________________
Do you drink coffee?	_____ Yes   _____ No 	if Yes, how much: _____________________________________
Do you participate in any physical activity?  _____Yes _____ No  if Yes, What type: __________________________
                                                          How often: ____________________________________
ALLERGIES: (please circle all the ones that apply) 
NONE 	    LOCAL ANESTHETICS	 PENICILLIN	     ASPIRIN    	ADHESIVE TAPE
LATEX      SULFUR PRODUCTS         CORTISONE        CODEINE	        OTHER(s): _________________

Adriana Strimbu, DPM, PA
                 404 N. Federal Hwy, Hallandale, FL 33009, Ph. (954) 455-9404, Fax (954) 455-9407
                                         www.hallandalebeachfootdoctor.com
						
						MEDICAL HISTORY
ILLNESSES: (Please check all that apply)
AIDS / HIV			Back Problems 		  High blood pressure     Numbness/Burning in feet
Anemia				Bleeding Disorders	  High Cholesterol	   Poor circulation	
Arthritis				Gout			  Kidney problems        Stroke
Artificial Heart Valves	       Heart Disease            Liver disease           Pacemaker
Artificial Joints			Headaches		  Lung problems          Defibrillator
Asthma				Hepatitis		  Neck pain	           Diabetes
Circulatory problems		Glaucoma		  Cataracts 		   Depression / Anxiety
Cancer: ________________________________          Other: ____________________________________________
Please list any MEDICATIONS that you are currently taking:________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please list any OPERATIONS/SURGERIES that you had had: ____________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
FAMILY HISTORY: Please write below what medical problems your other family members have or had.
Mother __________________________________ Father_____________________________________

Sister____________________________________ Brother____________________________________ 

I hereby give my permission to the doctor at the Adriana Strimbu, DPM, PA to perform 
diagnostic, therapeutic and/or operative procedures as may be deemed necessary in 
diagnosis and/or treatment of my feet and/or ankles.

PATIENT SIGNATURE:__________________________________________DATE: _____________________

Adriana Strimbu, DPM, PA
                 404 N. Federal Hwy, Hallandale, FL 33009, Ph. (954) 455-9404, Fax (954) 455-9407
                                          www.hallandalebeachfootdoctor.com

FINANCIAL POLICY
We are committed to providing you with the best possible care, and we are pleased to discuss our financial fees with you at any time. Your clear understanding of our Financial Policy is important to our professional relationship. 
PATIENTS BILLING: All patients are responsible for all co-payments, co-insurance, or deductible amounts at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payment and deductibles from patients can be considered fraud. As a courtesy, our office does verify benefits with your insurance carrier; however, the insurance agreement is a contract between you and your insurance carrier. We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. If you do not have health insurance you are responsible for the full payment at the time of service. If you are not insured by a plan we participate with, payment in full is expected at each visit. 
REFERRALS/AUTHORIZATIONS: We are required to follow the guidelines of your managed care plan which mandates us that when you visit as specialist such as ours, you must have a referral from your primary care physician prior to seeking specialty care. Therefore, you are financially responsible for the services received, unless your referral is presented at the time of this visit. It is your responsibility to contact your primary care physician to obtain your referral and bring it to our office for your visit or have them fax it to our office. If you do not have a referral from your primary care physician at the time of a visit, you will be financially responsible for all the services received due in full upon completion of the visit. Full credit will be given if a referral is presented to our office within 24 hours of this visit. You will also be given the option to reschedule your appointment.
MEDICARE: We are a participating Medicare provider. We accept Medicare benefit amounts. Medicare as well as your secondary insurance (if any) will be billed for you. However, that does not mean that all services are covered. Patients are responsible for paying their annual deductible if it has not yet been met. You are also responsible for any copayments, which are usually 20% of the allowed amount for an item or service.
SECONDARY INSURANCE: Your medical claim will be forwarded to your secondary insurance (if any) after payment and/or explanation of benefits (EOB) is received from your primary insurance company.
NON-COVERED SERVICES: Please be aware that some of the services you receive may not be covered or not considered reasonable or necessary by Medicare or other insurers. You are responsible for full payment of these services at the time of service.
NON-CUSTOM DURABLE MEDICAL EQUIPMENT RETURNS: If a patient is unsatisfied with any non-custom Durable Medical Equipment item, it must be returned within 30 days per Medicare guidelines. Returns after 30 days will not be permitted. The item will only be accepted as a return if it shows signs of no wear and must have the original wrapping or box.
REGARDING MINORS: The adult accompanying a minor, and his/her parent(s) or guardian(s) are responsible for FULL payment at the time of services. Non-Emergency treatment will be denied unless charges have been pre-authorized to an APPROVED agreement. 

CANCELLED/MISSED APPOINTMENTS: Unless cancelled at least 24 hours in advance, our policy is to charge $25 for any missed appointment.  If you miss 3 or more appointments, you may be required to pay a $50 deposit to hold any future appointment time slots. If you arrive late for an appointment, we may need to reschedule 
your appointment.  You will bear complete financially responsibility for any fee incurred. Repeated missed or late appointments may result in dismissal from our practice.  Please help us serve you better by keeping schedule appointments.
METHOD OF PAYMENT/COLLECTION FEES:  We accept the following payment methods: cash, check or Visa/Mastercard. An additional $25 fee will be added to your statement if the check is returned from your bank. In the event that the insurance company sends payment to you, the patient, it should be forwarded to our office to be applied to your balance.
You will be sent up to 3 notices for your financial responsibility(co-insurance, deductible) after payment and /or explanation of benefits (EOB) is received from your insurance company. After the 3rd and last notice, your account will be forwarded to our collection agency. If your account is sent to a collection agency, a 35% fee will be added to your account. You bear complete financial responsibility for any fees incurred.
I have read the above policy regarding my financial responsibility to Adriana Strimbu, DPM, PA for medical services provided. I agree to pay Adriana Strimbu, DPM, PA any balance unpaid by my insurance carrier for myself or the below named person.
PRIVACY STATEMENT:  Any information disclosed in your records will remain confidential and will not be used for any  other reason except in providing quality care and treatment as well as to submit your claim to your insurance company and contact you as needed.
PATIENT ACKNOWLEDGE OF NOTICE OF PRIVACY PRACTICES:  By subscribing my name below, I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have ( or had the opportunity to read if so choose) and understand the Notice and agree to its terms.
Assignment of Benefits:  I, the undersigned, certify that I (or my dependent) have coverage with my insurance as presented and assign directly to Adriana Strimbu, DPM, PA all insurance benefits, payable to me for services rendered. I understand that I am responsible for payment of deductibles, co-payments, co-insurance, non-covered services and other fees AT THE TIME OF SERVICE. I hereby authorize the doctor to release all information necessary to secure payment of benefits. I authorize Release of Medical Information to my insurance carrier or requested physician to provide continuity of care. I authorize the use of this signature on all insurance submissions.
I understand that it is my responsibility to inform the doctor’s office if there is a change in my health insurance information and acknowledge I was provided with a copy of the Notice of Privacy Practices and understand and accept its terms.
PRINT Patient Name: ________________________________    Date: __________________

Patient’s Signature: __________________________________ 

FINANCIALLY RESPONSIBLE PARTY:
PRINT Name: __________________________________  Signature:_____________________
Relationship to Patient: __________________________  Date: ________________________

INSURANCE AUTHORIZATION
I understand that I have provided Dr. Strimbu with information on proper insurance cards that will be copied and kept in my file for records. I also agree to let Dr. Strimbu know of any changes of insurance status prior to my visit. By signing this form I give permission to Adriana Strimbu, DPM, PA or its representatives to bill the insurance on my behalf. Any copay is due at the time of service. If NO medical insurance is provided, I understand that the money is DUE at the time of service unless prior agreements were made. I understand that billing the insurance company is a favor provided by Adriana Strimbu, DPM, PA. However after two unsuccessful attempts of collecting the money for services rendered, I will be billed directly from Dr. Strimbu's office. After unpaid balance of 90 days, I will be turned into a collecting agency. I understand the above statement.
SIGNATURE: 	________________________________________________	DATE: 	__________________________

Adriana Strimbu, DPM, PA
                 404 N. Federal Hwy, Hallandale, FL 33009, Ph. (954) 455-9404, Fax (954) 455-9407
                                     www.hallandalebeachfootdoctor.com

PATIENT INFORMATION CONSENT FORM

I had read and fully understand Adriana Strimbu, DPM, PA's Notice of Information Practices. I understand that Adriana Strimbu, DPM, PA may use or disclose my personal health information for purposes of carrying out treatment, obtaining payments, evaluating the quality of services provided and any administrative operations related to treatment or payment. I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment and administrative operations if I notify Adriana Strimbu, DPM, PA will consider requests on a case-by-case basis, but does not have to agree to requests for restrictions. 

I hereby consent to the use and disclosure of my personal health information for purposes as noted in the Adriana Strimbu, DPM, PA's Notice of Information Practices. I understand that I retrain the right to revoke this consent by notifying Adriana Strimbu, DPM, PA in writing at any time. 

PATIENT'S NAME:
_________________________________________________________________________________________________
PATIENT'S SIGNATURE:
_________________________________________________________________________________________________
DATE:
_________________________________________________________________________________________________