Download EvenKeel | Podiatry

EvenKeel | Podiatry
1180 Beacon St. Suite 4D
Brookline, MA 02446
www.santopietro.com
p. 617.734.0003
f. 617.734.0683
go to santopietro.com
Frank J. Santopietro, D.P.M.
Patient Information
First Name
Last Name
Gender F | M | U
MI
Race
Date Of Birth
(mm/dd/yyyy)
Ethnicity
Address 1
Cell Phone
Address 2
Home Phone
City
Work Phone
Zip
State
Email
How should we contact you?
Postal Address
|
Marital Status
Email
S | M | D | W
How did you learn of EvenKeel Podiatry &/or Dr. Santopietro?
Insurance Information
A copy and / or scan of your insurance card and photo ID will be required at the time of your office visit.
Primary Insurance Company
Policy Number
Group Number (if applicable)
Co-Pay (if applicable)
Subscriber Information (if different from patient):
Last Name
First Name
Date of Birth
(mm/dd/yyyy)
Patient’s Primary Care Physician (PCP) or Referring Provider
Medical History Part 1: Orthopedic Information
Do you have any current foot problems? If yes, explain:
Duration of current problem:
Has it been treated previously?
If Yes, please explain the treatment:
Do you have any current back, knee, hip, or leg problems? If yes, explain:
Duration of current problem:
Has it been treated previously?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
If Yes, please explain the treatment:
Do you have Osteoperosis or Osteopenia?
Have you ever had a bone density examination?
Do you have any heart, lung or kidney issues?
Medical History Part 2: Medication Information
List any medications you are taking:
List any medications you are allergic to:
EvenKeel | Podiatry
Frank J. Santopietro, D.P.M.
1180 Beacon St. Suite 4D
Brookline, MA 02446
www.evenkeelpodiatry.com
p. 617.734.0003
f. 617.734.0683
Thank you for choosing EvenKeel Podiatry & Dr. Frank J. Santopietro,
D.P.M. for your foot and lower extremity care. Ours is a unique, conservative care, biomechanics based podiatry practice. Surgery is considered as
a last resort.
Office Visits: Most insurance companies cover the cost of each office visit. HMO Blue, Blue Choice,
Tufts, Harvard Pilgrim and all other managed care companies require a referral from your primary
care physician for each visit. The cost of an initial visit is $250.00. Subsequent exams and/or visits
cost $125.00. Office visit costs are billed through your insurance company. Most managed care plans
also require a co-pay at the time of visit. Accepted forms of payment include the following: cash,
check, Visa, Master Card, Discover, American Express. Any co-insurance obligations you may have, as
determined by your insurance provider, for office visit or other podiatric services provided, will be
billed following the provision of services.
Orthotics: Should you choose to receive custom orthotic therapy, our experienced staff will dispense
your orthotics within an hour and a half after seeing Dr. Santopietro. The cost of the initial orthotic is
$400.00. With our orthotic therapy, a second visit 2 to 3 weeks after the first is necessary to ensure
proper function, fitting and comfort. Some foot problems require additional visits in the first 3 to 4
months. Additions to the orthotics may be needed and costs vary between $45 to $120 dollars. This
is left to the discretion of the doctor. Payment is expected at the time of service. Insurance companies are not billed for custom orthotics.
Shoes and Accessories: Dr. Santopietro frequently recommends the Brooks Beast and Ariel line of
sneakers. To properly ensure fit and treat patients, the doctor chose to carry and sell these shoes in
his office. The price of sneakers is $150.00. Also, Feetures socks are sold in a variety of sizes and
lengths and costs vary on style between $10.00 and $15.00. Other recommended shoes and accessories can be found at www.evenkeelpodiatry.com.
My signature below confirms that I have read, understand
and agree to the above Financial Policies.
Patient Name (please print):_____________________________________________
Patient
(guardian)
Signature:_________________________________________Date:______________
EvenKeel | Podiatry
Frank J. Santopietro, D.P.M.
1180 Beacon St. Suite 4D
Brookline, MA 02446
www.santopietro.com
p. 617.734.0003
f. 617.734.0683
PATIENT AUTHORIZATIONS
Authorization to Release Information for Insurance Purposes: I hereby authorize Dr.
Frank Santopietro to release any information in the course of my examination and/or
treatment to my insurance company(ies) for the purpose of billing. I also authorize the
release of information to my employer if my examination and/or treatment are work related.
Authorization to Pay Benefits to Physician: I hereby authorize the medical and/or surgical
benefit payments to be made directly to Dr. Frank Santopietro. I understand that I am
financially responsible for all charges not covered by my insurance company(ies) and this
authorization.
Informed Consent for Office Procedures: I hereby authorize Dr. Frank Santopietro and his
staff to perform those diagnostic and/or office procedures including biomechanical
examination, diagnositic photographs and non-invasive foot scans deemed necessary to
evaluate and/or treat my current medical condition(s). I understand that the scan of my foot is
NOT an X-ray but rather a color photo scan. I retain the right to verbally refuse any
procedure, either diagnostic or therapeutic, after being informed of its nature, complications,
and side effects.
Acknowledgement of Notice of Privacy Practices: Our Notice of Privacy Practices
describes in more detail how your health information may be used and disclosed, and how
you can access your information. My signature below confirms that I have received Dr.
Santopietro's Notice of Privacy Practices.
My signature below confirms that I have read, understand
and agree to the above Patient Authorizations.
Patient Name (please print):___________________________________________
Patient
(guardian)
Signature:___________________________________Date:___________