EllenW enzel,DP M ,FA CFA S ,FA CFA O M
ZarkoKajgana,DP M ,FA CFA S ,FA CFA O M
Kelsey Barrick,DP M
601 S E117th Ave
S uite240
Vancouver,W A 98683
(360)977-7815 O ffice
(888)568-4875 Fax
w w w .ankleandfootphysicians.com
P atientInform ation
FirstN am e
M iddleInitial
DateofBirth
Gender
Address
P honeN um ber(
M
L astN am e
S uffix
F M aritalS tatus
SSN #
City
)
P referredL anguage
S tate
CellN um ber(
English
O ther
)
R ace(O ptional)
ID/P olicy N um ber
ID/P olicy N um ber
GroupN um ber
GroupN um ber
N am eofP olicy Holder
N am eofP olicy Holder
DateofBirthofP olicy Holder
DateofBirthofP olicy Holder
R elationshiptoP atient
R elationshiptoP atient
Auto
ZipCode
Hispanic/L atino?
S econdary Insurer
W ork
-
__________________
Insuranceand O therCoverageInform ation
P rim ary Insurer
Isthisaninjury related to:
-
O ther ___________ IfYes,Date/T im eofInjury
Yes
No
__________
Claim M anager/L egalR epresentativeContactInform ation________________________________________________
P rim ary Careand R eferralInform ation
P rim ary CareP rovider
P referred P harm acy
P harm acy N am e
_______________
W hom m ay w ethankforyourR eferral?
AddressorCrossS treets
Em ploym entInform ation
Em ployer
Address
P honeN um ber(
Em ergency Contact
N am e
O ther
Em ployed
R elationshiptoP atient
___________________________________________________________
S ignatureofP atient/P atientR epresentative
N one
____________
S tate
S tudent
_________
_________________________
Job T itle
City
)
P CP
R etired
ZipCode
U nem ployed
_____
_____
O ther ________
P honeN um ber(
)
________________________________
Date
U pdated 2017.01.21
EllenW enzel,DP M ,FA CFA S ,FA CFA O M
ZarkoKajgana,DP M ,FA CFA S ,FA CFA O M
Kelsey Barrick,DP M
601 S E117th Ave
S uite240
Vancouver,W A 98683
(360)977-7815 O ffice
(888)568-4875 Fax
w w w .ankleandfootphysicians.com
S U M M A R Y O FN O T ICEO FP R IVA CY P R A CT ICES
T hissum m ary isprovided toassistyou inunderstandingtheattached N oticeofP rivacy P ractices
T he attached N otice ofP rivacy P racticescontainsadetailed
descriptionofhow ourofficew illprotectyourhealth
inform ation,yourrightsasapatientand ourcom m on
practicesindealingw ithpatienthealthinform ation. P lease
referto that N otice forfurtherinform ation.
U sesand DisclosuresofHealthInform ation
W ew illuseand disclose yourhealthinform ationinorderto
treatyou ortoassistotherhealthcareprovidersintreating
you. W ew illalsouseand disclose yourhealthinform ationin
orderto obtainpaym entforourservicesortoallow
insurancecom paniesto processinsuranceclaim sforservices
rendered to you by usorotherhealthcareproviders. Finally,
w em ay discloseyourhealthinform ationforcertainlim ited
operationalactivitiessuchasquality assessm ent,licensing,
accreditationand trainingofstudents.
U sesand DisclosuresBased onYourA uthorization
Exceptasstated inm oredetailin the N oticeofP rivacy
P ractices,w ew illnotuseordiscloseyourhealthinform ation
w ithoutyourw rittenauthorization.
U sesand DisclosuresN otR equiringYourA uthorization
Inthefollow ingcircum stances,w em ay disclose yourhealth
inform ationw ithoutyourw rittenauthorization:
•
T o fam ily m em bersorclose friendsw hoareinvolved in
yourhealthcare;
•
Forcertainlim ited researchpurposes;
•
Forpurposesofpublichealthand safety;
•
T o Governm entagenciesforpurposesoftheiraudits,
investigationsand otheroversightactivities;
• T ogovernm entauthoritiestopreventchild abuseor
dom esticviolence;
• T o the FDA to report product defectsorincidents;
• T olaw enforcem entauthoritiestoprotectpublicsafety
orto assistinapprehendingcrim inaloffenders;
• W hen required by court orders,searchw arrants,
subpoenasand asotherw iserequired by thelaw .
P atientR ights
Asourpatient,you havethefollow ingrights:
• T o have accessto and/oracopy ofyourhealth
inform ation;
• T o receiveanaccountingofcertaindisclosuresw ehave
m adeofyourhealthinform ation;
• T o request restrictionsasto how yourhealth
inform ationisused ordisclosed;
• T o requestthatw ecom m unicatew ithyou inconfidence;
• T o request that w e am end your healthinform ation;
• T oreceivenoticeofourprivacy practices.
Ifyou haveaquestion,concernorcom plaintregardingourprivacy practices,pleaserefertotheattached N oticeofP rivacy P ractices
forthe person orpersonsw hom you m ay contact.
A CKN O W L EDGM EN T O FR ECEIP T O FN O T ICEO FP R IVA CY P R A CT ICES
Iacknow ledge thatIw asprovided acopy ofthe N otice ofP rivacy P racticesand thatIhaveread (orhad the
opportunity toread ifIsochose)and understoodtheN otice.
Inaddition,Irequestthefollow ingrestrictionsregardingm y P rotectedHealthInform ationbeplaced onm y account:
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
S ignature
Date
P atientN am eO R O therAuthorized R epresentative
R elationshiptoP atient
U pdated 2017.01.21
EllenW enzel,DP M ,FA CFA S ,FA CFA O M
ZarkoKajgana,DP M ,FA CFA S ,FA CFA O M
Kelsey Barrick,DP M
601 S E117th Ave
S uite240
Vancouver,W A 98683
(360)977-7815 O ffice
(888)568-4875 Fax
w w w .ankleandfootphysicians.com
P atientFinancialP olicy and A ssignm entofBenefits
Yourunderstandingofourfinancialpoliciesisanessentialelem entofyourcareand treatm ent.Ifyou haveany questions,please
discussthem w ithourfrontofficestafforsupervisor.
 U nlessotherarrangem entsare m adein advanceby you,oryourhealth insurancecarrier,paym entforoffice servicesaredueatthe tim e
ofservice.W eacceptVisa,M asterCard,Discover,Am ericanExpress,cash,orcheck.
 Asourpatient,you areresponsibleforauthorizations/referralsnecessary fortreatm ent.You m ustinform theofficeofinsurancechanges
and authorization/referralrequirem entsand,ifnecessary,presentauthorization at the tim e ofvisit;ifthe practice isnotinform ed,you
w illberesponsibleforany chargesdenied.
 Yourinsurancepolicy isacontractbetw eenyou andyourinsurancecom pany.Asacourtesy,w ew illfileyourinsuranceclaim ifyou assignthe
benefits(in otherw ords,the direct paym ent)to Ankle and Foot P hysiciansand S urgeons,P L L C orthe physician individually,forservices
renderedtoyourselforyourdependent(s)by thephysicianorunderhis/herdirection.Ifyourinsurancecom panydoesnotpay inareasonable
tim efram e,w ew illhavetolooktoyou forpaym ent.
 W e have contractsw ith m any insurers/health plansto accept an assignm entofbenefits.W e w illbillthose plansw ith w hich w e have an
agreem entand w illonly requireyou topay theco-pay/co-insurance/deductible.
 Ifw e are notcontracted w ith yourinsurance plan,w e w illprepare and send the claim foryou on an unassigned basis;yourinsurerm ay
send thepaym entdirectly toyou.T herefore,allchargesforyourcareand treatm entaredueatthetim eofservice.
 S om eservices,im aging,procedures,and/ordurablem edicalgoodsm ay haveaco-pay/co-insurance/deductibleseparatefrom officevisits
orin som e instancesm ay notbe covered by yourparticularm edicalplan.In eitherinstance,these are separately billable and payable by
you,theinsured.
 It isnecessary in the subm ission ofhealth insurance claim sto send certain personalinform ation and/orpartsofthe non-publicpatient
record.You consenttothereleaseofyouroryourdependent(s)record(s)forthispurpose.
 W orker’sCom pensation/L aborand Industriesclaim sm ustbe broughtto the attention ofthe staffatthe tim e ofscheduling.Ifyou have
notyetfiled yourclaim ,you m ay fileinoffice.You m ustprovideasecondary form ofpaym entintheeventyourclaim isdenied;ifclaim is
denied,the balance ofallprofessionalservicesrendered ispayable in full,by you.W orker’scom pensation claim scannot be billed to a
privateinsurerunlesstheclaim hasbeendenied,doesnotexists,orhasbeenclosed.
 Ifyou are being treated forinjuriesresulting from aM otorVehicle Accidents(M VA),the claim m ustbe subm itted to yourM otorVehicle
(P IP )Carrierand cannot be billed to aprivate insurance plan unlessthe P IP claim hasbeen denied,coverage doesnot exist,orprivate
insurancew asselected asprim ary carrier.You areresponsibleforany deductiblesand/orco-paym entsunderyourP IP coverage.You also
agree,to havealienplaced againstany settlem entthatyou m ay receiveduetoanM VA clAIM forw hich you aretreated by P IP coverage,
topay any open/unpaid balancesduetoAnkleand FootP hysiciansand S urgeons,P L L C orherphysicians.
 Allhealthplansarenotthesam eand donotcoverthesam eorallservices.Ifyourinsurerdeterm inesaserviceoritem tobe"non-covered,"
forany reason,you areresponsibleforthechargesand m ay berequested topay in fullattim e ofservice.W ew illattem pttoverify benefits
forsom especialized servicesorreferrals;how ever,you rem ainresponsibleforchargesforany servicerendered.P atientsareencouraged to
contacttheirplansforclarificationofbenefits.
 Hospitaland outpatientsurgery servicesarebilled to the insurer.A ny balancedue isyourresponsibility.
 Certain elective surgicalproceduresm ay require pre-paym ent.You w illbe inform ed in advance ifyourprocedure isone ofthose.In that
event,paym entw illbedueonew eekpriortothesurgery.
 Accountsm orethan90 dayspastduew illbeconsideredfortransfertocollections.Allcostsincurredincluding,butnotlim itedto,collection
fees,attorney feesand courtfeesshallbeyourresponsibility inadditiontothebalancedue.
 T hereisaservicefeeof$50.00 forallreturned checks.Yourinsurance com pany doesnotcoverthisfee.
 W e understand em ergenciesoccur,how ever,repeated no-show sorcancellationsw ith lessthan 24 hournotice are subjectto a$50 noshow /late cancellation fee;thisisnotcovered by yourinsurer.P atientsw ho arrive m orethan 10 m inuteslate fortheirappointm entm ay
beasked toreschedule.
_______________________
S ignature
________________________
P rintedN am e
______________________________
R elationship(ifnotP atient)
_____________
Date
U pdated 2017.01.21
EllenW enzel,DP M ,FA CFA S ,FA CFA O M
ZarkoKajgana,DP M ,FA CFA S ,FA CFA O M
Kelsey Barrick,DP M
601 S E117th Ave
S uite240
Vancouver,W A 98683
(360)977-7815 O ffice
(888)568-4875 Fax
w w w .ankleandfootphysicians.com
Consentsand A cknow ledgem ents
ConsenttoR eleaseofInform ation
Inordertofacilitateand coordinatetreatm entand toconductbusinessincludinginsurancebenefitpaym ent,w em ustreleasecertain
healthinform ationtootherprovidersand insurers.
 Asourpatient,you hereby authorizeAnkleand FootP hysiciansand S urgeons,P L L C,and herphysiciansindividually,toreleaseyour,or
yourdependent(s)m edicaland incidentalnon-publicpersonalinform ationthatm ay benecessary form edicaltreatm ent,evaluation,
consultation,ortheprocessingofinsurancebenefits.
ConsenttoCom m unication
Ankleand FootP hysiciansand S urgeons,P L L C w illroutinely usem ail,telephonecallsand/orm essagesinthedelivery ofcaretorelay
appointm entand/orhealthcarerem inders,updatesonreferralarrangem ents,and thereceiptoflaboratory results,unlessotherw ise
requested.
 You havetherighttolim itthem ethodsofcom m unicationthatoriginatefrom ouroffice.Ifyou haverestrictionsthatyou w ould liketo
placeonyouraccount,w ew illbem orethanhappy toplacethose.Ifatany tim eyou w ishtorescind thisauthorization,you m ay doso
by notifyingAnkleand FootP hysiciansand S urgeons,P L L C inw ritingofthechangesthatyou w ishtom ake.
 Ifyou electtouseem ailasam ethod ofcom m unicationw iththeoffice,you certify thatyou understand therisksand w ew illrequirea
separateauthorization.Em ailshould neverbeused fortim esensitivem atters.
ConsenttoT reatm ent
 You hereby consenttotheevaluation,testing,and treatm ent(s)asdirected by Ankleand FootP hysiciansand S urgeons,P L L C and her
physician(s)and/ordesignee(s).
ConsenttoP hotography
 Asourpatient,photographs,video,orotherim ages(digitaloranalog)m ay beem ployed todocum entyourcare,and yoursignature
below indicatesyourconsenttothis.Yoursignatureindicatesthatyou understand thatAnkleand FootP hysiciansand S urgeons,P L L C
w illretainow nershiprightstothesephotographs,videotapes,digital,orotherim ages,butthatthatyou w illbeallow ed accesstoview
them orobtaincopies.You understand thattheseim agesw illbestored inasecurem annerthatw illprotectyourprivacy and thatthey
w illbekeptforthetim eperiod requiredby law orperpolicy ofAnkleand FootP hysiciansand S urgeons,P L L C.
FeesforAdditionalR eports,Form s,R ecords,Etc.
 R equestsforcom pletionofdisabilityform s,reports,orotherpaperw orkm ay requireafee,payableinadvance,relatedtotheam ountof
preparationinvolved.P leaseallow 5-7businessdaysforcom pletionofany disability form s.
Ifthenecessarydisabilityform sarerelatedtoeitheranon-electiveorelectivesurgery,yoursurgeonm ay electtocom pletetheseform satno
fee,butthey w illnotbecom pletedpriortothepreoperativeexam inationdate.Form sw illbecom pletedandavailablepriortoyourscheduled
surgeryday.
 R adiographsperform edinourofficeareanintegralpartofyourm edicalrecord.Feesfordigitalcopiesofyourfilm s,advancedim aging,or
copiesofoutsidestudies(i.e.onCD-R O M )w illbechargedbasedonguidelinesassetforthby theW ashingtonS tateDepartm entofHealth.For
thecurrentpricelist,contactthefrontofficestaff.
 M edicalrecordsrequestsw illbeprocessedw ithin5-7businessdaysoftherequestandfeesforrecordsprocessingarebasedonguidelinesas
setforthby theW ashingtonS tateDepartm entofHealth.Forthecurrentpricelist,contactthefrontofficestaff.
N oticeofP rivacyP ractices
 Icertify thatIhavebeengiven orhavebeenoffered and/orread (and understood)theHIP AA N oticeofP rivacy P racticesthatis
availablefrom Ankleand FootP hysiciansand S urgeons.
_______________________
S ignature
________________________
P rintedN am e
______________________________
R elationship(ifnotP atient)
_____________
Date
U pdated 2017.01.21
FO R O FFICEU S EO N L Y
P atientN am e
DateofBirth
VisitInform ation
P AT IEN T ID
P CP
DM EAL ER T 
R EFER R IN G
W hy areyou seeingthedoctortoday?
_____________
W hendid thisproblem begin?
___________________________
Isthisaninjury duetoanaccident?
Doyou havepain?
Yes
Yes
No
Ifyes:Dateand T im eofInjury
N o Ifyes:doesitvary?
Yes
N o Doesitradiate?
W ork
Yes
Auto
N oW here?
O ther
___
______
W hatcausesoraggravatesthepain?
W hathaveyou tried forpainrelief?
______
W hatw orksbesttorelievethepain?
AdditionalFactors
______
P astM edicalHistory
M edicalhistory reported by:
S elf
O ther
Doyou now haveO R haveyou everhad any ofthefollow ing:
Constitutional/General
Gastrointestinal
Cancer
Acid reflux/GER D
T ype
___________
Cholecystitis
U nexplained
Hiatalhernia
Fever Chills
IBS
N ightsw eats
S tom ach/bow elproblem s
W eightL oss
U lcers
Cardiovascular
Genito-U rinary
Angina
Fem ales:DateofL M P
__
Blood clots/DVT
Bladderorkidney stones
Edem ainthelim bs
Infection/U T Is
EKG
L astEKG
___
Kidney failure
HeartAttack/M IDate
T ype
___________
Highblood pressure/HT N
Dialysis
HighCholesterol
P rostatedisease
Irregularheartbeat
S T Ds
P eripheralVascularDisease
T ype
__________
R heum aticfever
Endocrine
Valveproblem sofHeart
Diabetes
R espiratory
Hyperthyroid
Asthm a
Hypothyroid
ChronicCough
Hem atologicDisease
CO P D
Anem ia
Em physem a
T ype
___________
S leepApnea
Easy bruising/bleeding
U singCP AP ?
Yes N o
S ickleCellDiseaseorT rait
R elationshiptopatient
_________________________
InfectiousDiseases
Hepatitis
T ype
___________
HIV/AIDS
T uberculosis/T B
L iver
Cirrhosis
Jaundice
M usculoskeletal
Arthritis
T ype
___________
Backpain
Backinjury
Fracture(s)
L ocation(s)
________
L im b orJointDeform ity
Describe
__________
L im b orJointP ain
Describe
__________
JointP rosthesis
L ocation(s)
________
M usclew eakness
M usculardystrophy
T ype
___________
M uscularsclerosis
P aralysis
S pecialS enses
Double/blurred vision
Glaucom a
Hearingdeficit/loss
Hearingaids
M aculardegeneration
Visionchanges
Contacts Glasses
N ervoussystem
Anxiety
CharcotM arieT ooth
Convulsions/epilepsy
Dem entia
Depression
Fainting
Inherited N euralDisorder
T ype
___________
M igraines
S troke
W eakness L eft
R ight
N europathy
T ype
___________
O ther
____________
_________________________
_________________________
M edications
P leasenote:Includeprescriptions,overthecounter,vitam insand supplem ents.You m ay alsosubm itacurrentm edicationlist.
M edication
Dosage
Frequency
M edication
Dosage
Frequency
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
U pdated 2017.01.21
A llergies
P leaseindicateallallergies,includingthosetom edicationand food.
N oKnow nDrugA llergies
M edication
R eaction
M edication
R eaction
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
Food allergies
Eggs
Guava
Kiw i
P eaches
NO NE
N uts
S eafood/S hellfish
O ther
___________
_________________
Environm ental/O therallergies
Adhesives
Anesthetics
T ype
___________
L atex
NO NE
Band Aids/T ape
Gloves
O ther
____________
__________________
S urgicaland HospitalizationHistory
S urgeries(pleaseincludetypeAN D year)
____________________________________________________________________
______________________________________________________________________________________________________
Any com plicationsduetoanesthesia?
Yes
N oDescribe
Hospitalizations(pleaseincludereasonAN D year)
___________________________________________________
_____________________________________________________________
______________________________________________________________________________________________________
S ocialand P reventativeHistory
Doyou use: cigarettesorsim ilar
Ifno,haveyou inthepast?
Doyou drinkalcohol?
Doyou drinkcaffeine?
Yes
Yes
chew
Yes
vape/e-cigsHow m any packs/cansperday?
No
How m any packs/cansperday?
No
No
How m any glasses/drinksperday?
How m any cups/drinksperday?
Doyou useany illicitdrugs(e.g.m arijuana,cocaine,heroin,etc.)?
Ifno,haveyou inthepast?
Yes N o
Yes
No
W hich?
W hich?
_____ How m any years?
_____ How m any years?
_______________________
________________________
_______________________
_______________________
Areyourim m unizations(e.g.tetanus,diphtheria,pertussis– T dapand M easles,M um ps,R ubella– M M R )current?
Yes N o
Indicateyearofm ostrecent: T dapbooster
__________ M M R booster
__________ Flu S hot
________
Haveyou received the: P neum onia(P neum ovax)vaccine?
Yes N o HepatitisB vaccine?
Yes N o
O therelectivevaccines?
Yes N o
W hich?
_______________________
Fam ily History
P leaseindicateknow nm edicalhistory offirstdegreerelatives(e.g.diabetes,heartdisease,glaucom a,am putation,kidney dx,etc).
Age(orAgeatDeath)
Diseases
M other
Father
S iblings
Children
M aternalGrandparents
P aternalGrandparents
__________________________________________
______________________
S ignatureofP atient/P atientR epresentative
Date
U pdated 2017.01.21