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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:___________