New Patient Form

PODIATRIC REGISTRATION AND HISTORY

Step 1 of 2

DR. JOSEPH BARAK

PATIENT INFORMATION

MM slash DD slash YYYY
Sex(Required)
Marital Status(Required)
Employer Address(Required)

Spouse's Information:

INSURANCE

Is patient covered by additional Insurance?(Required)

ASSIGNMENT AND RELEASE

and assign directly to Dr. Joseph Barak all insurance benefits. If any otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

MEDICARE AUTHORIZATION

I request that payment of authorized Medicare benefits be made either to me or on my behalf to Dr. Josph Barak for any services furnished me by that physician. I authorize any holder of medical information about me to release to the Health Care Financing. Administration and its agents any information needed to determine these benefits or the benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If "Other health insurance" is indicated in item 9 of the HCFA-1500 form. or elsewhere on other approved claim forms or electronically submitted claims. my signature authorized releasing of the information to the insurer or agency shown. In Medicare assigned cases. the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full Charge. and the patient is responsible only for the deductible. co-insurance. and non- covered services. Co-insurance and the deductible are based upon the charge determination of the Medicare carrier.

IN CASE OF EMERGENCY, CONTACT

CONTACT INFORMATION

MEDICATIONS

Do you take oral contraceptives?(Required)
ALLERGIES(Required)
Do you take alcohol?