Intake Form


Please complete the following form and answer all questions before arriving for your appointment.

Be sure to include your insurance information.
We'll see you soon!

Patient Information

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Social History
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Family History

Which family members had the below medical conditions? (father, mother, sibling, etc.)

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Insurance Information

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Emergency Contact

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Responsible Party (if minor patient)

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Consent for Treatment and Acknowledgement of Policies

For any insurance plan that requires authorization from a primary care physician (e.g. HMO, PPO, etc.) it is your responsibility (as patient or guardian) to be sure that this office receives all necessary referrals or authorizations PRIOR to treatment. Professional services are rendered and billed directly to your insurance carrier; however you, the patient/guardian, are directly responsible for services rendered by the doctor. A health insurance policy is a contract between you (the patient or subscriber) and your insurance carrier. You MUST notify this Office of any changes to your insurance policy including policy termination, changes in co-payments or a new insurance policy. If for any reason the insurance carrier denies charges, payments for any services rendered will become the responsibility of the patient/guardian.
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All office visit charges and co-pays are due at the time services are rendered. It is the patient who is responsible for any and all financial aspects of services rendered. There will be a charge for returned checks, missed appointments without 24 hours notice and completion of any forms. I agree to pay for all deductibles, co-pays, non-covered services and any portion of covered services not paid in full by my insurance plan and understand that such payments are due at the time of service or immediately upon presentation of the bill. I hereby name Kirk Podiatry (KP) as my assignee. I instruct my health care benefits plan administrator, i.e. PLAN to pay KP directly for all professional and medical services provided by KP through the means of electronic funds transfer(s) (EFT) or by check(s) made payable to and mailed to KP. I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS CLAIMS.
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The above information is correct to the best of my knowledge. I understand that throughout my treatment, I am responsible for notifying the physician and/or medical staff of any and all updates to the information listed above. I also give permission for photographs of my feet to be taken that are to be kept as part of my medical record only. They will not be published as part of medical research or disbursed in any way without my permission.
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I acknowledge that I was provided a copy of the Notice of Privacy Practices for Kirk Podiatry and I have read (or had the opportunity to read if I so choose) and understood the Notice.
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PAYMENT RESPONSIBILITIES

We are pleased to welcome you to our office. New Patients are always appreciated. Our practice has grown as a result of its excellent relationship with our referring doctors and patients. As our patient, please feel free, at any time, to express any concerns or to ask any questions that you may have for the doctor or our staff. In order to assist you in making payment(s) for your podiatric treatment, the following options are listed. Please read them carefully and feel free to discuss them with us.

If you DO NOT have insurance: Payment is due, in full, at the time treatment is provided.

*For your convenience, we accept all major credit/debit cards and cash. We accept personal checks for payments under $50.00.

If you have Insurance: The percentage of coverage by your insurance company may be based on your insurance company’s own reduced fee schedule for medical services and may be less than actual charges resulting in lower coverage for you. Kirk Podiatry has no control over this situation. Lower payment is a direct result of the plan selected by you or your employer. Please be advised that we cannot waive co-payment. We are required by law to collect co-payment.

Commercial Insurance: We will submit your claim to your insurance carrier for you. You are responsible for any deductible or co-payment not covered by your insurance. Once our office has received payment from the insurance company, you will be billed, with 30 day terms, for any amount still owed. You may choose to keep a credit card on file for those balances left to you by your insurance company.

Medicare: This office accepts Medicare assignment. Medicare patients are fully responsible, however, for the initial yearly deductible and the 20% co-insurance. Federal law requires that physicians collect this amount. If you have a secondary insurance to cover the 20%, we will submit the balance to that insurance for payment and you will only be responsible for the yearly deductible.

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Financial Policy

Your insurance policy is a contract that exists between you and your insurance company. Our relationship is with you, the patient, and not the insurance company. If you have questions about your policy, please call the phone number provided on the back of your insurance card. The patient or responsible party is responsible for their bill being paid in full. Upon your initial visit you will be asked to provide a photo ID. Please inform us at every visit of any changes to your insurance coverage and provide us with your most recent card.
COPAYMENTS: It is a requirement of your insurance company that we collect your co-pay. Payment is required before meeting with the doctor.
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DEDUCTIBLES & CO-INSURANCE: If you have a high deductible plan, we may collect a $125 deposit to apply towards your deductible and co-insurance. Any remaining balance after submission to your insurance company is your responsibility.
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SELF PAY (for non-covered products and services and for patients without insurance coverage): Full payment is due at time of service. Payment for evaluation and management services at minimum will be required before seeing the doctor. Additional procedures/services may be recommended by the doctor. You will be informed of these charges before proceeding with treatment.
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REFERRAL: If your insurance plan requires a referral from your primary care doctor, this will be required at the time of your visit. Without a referral available, we will need to reschedule your appointment.
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NO SHOW (failure to present for your appointment): 24 hours-notice is required for cancellation of your appointment and failure to do so will incure a $50 Failure to provide 24 hours-notice for a scheduled office procedure will incur a $100 fee.
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SURGERY CANCELLATION: Failure to provide 5 business-days' notice before surgery will incur a $500 fee.
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BALANCES/COLLECTIONS FEES: If payment of an outstanding balance is not received within 30 days from the postmark date of a mailed statement or e-statement time stamp, a $10 re-billing fee may be added to each additional statement. Our patient portal offers the ability to view statements and submit payments conveniently and securely. Patients with balances more than 90 days overdue will be turned over to collections and a $35 administrative fee will be applied.
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FMLA/DISABILITY/MEDICAL RECORDS: There is a $40 charge for having the doctor complete these forms. Requested forms will be completed within five business days of diagnosis and care plan. There is a $30 fee to obtain a copy of your medical records.
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I have read and understand these financial policies.
Credit Card on File Agreement read more here
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Authorization for release of medical record information

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Please Note: Copy Fee May Be Charged for Medical Records
Above listed patient authorizes the following healthcare facility to make record disclosure:
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RESTRICTIONS: Only medical records originated through this Healthcare facility will be copied unless otherwise requested. This authorization is valid only for the release of medical information dated prior to and including the date on this authorization unless other dates are specified.
I understand the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse.
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This information may be disclosed and used by the following individual or organization:
Release to: Kirk Podiatry
Address: 9486 Hwy 412 West
City, State, Zip: Lexington TN 38351
Phone: (731) 249-5230
Fax: (731) 506-4888
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I understand i may revoke this authorization at any time. I understand that if i revoke this authorization i must do so in writing and present my written revocation to the health information management department. I understand that the revocation will not apply to information that has alread been released in response to this authorization. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company hen the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event, or condition.
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If i fail to specify and expiration date, event or condition this authorization will expire 1 year from the date signed.
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I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that i may inspect or obtain a copy of the information to be used or disclosed as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for an unautohrized redisclosure and the information may not be protected by federal confidentiality rules. If i have questions about disclosure of my health information, i can contact the authorized individual or organization making disclosure.
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I have read the above foregoing Authorization for Release of Information and do hereby acknowledge that i am familiar with and fully understand the terms and conditions of this authorization.
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