Past Medical History (Check those applicable)



Past Surgical History/Hospitalization (Check those applicable)


Medication or Bring complete List


Social History


Family History

Current Condition (Do you currently suffer from any of the following?)

Patient Information

Primary Insurance

Secondary Insurance

Release of Information

For the purpose of payment, I allow North Star Foot and Ankle Associates, P.A. to release my private Health Information to any and all of my insurance carriers, their third party payors and claim reviewers, until the claim is resolved. For the purpose of treatment, I also allow the above listed practice to release my information or contact any and all of my treating physicians.

Whom if anyone, may we release your medical information to:

Patient Financial Policy

* As our patient, you are responsible for all authorization/referrals needed to seek treatment in this office. You must inform the office of all personal and/or insurance change and authorization referral requirements. In the event the office is not informed, you will be responsible for any charges denied.

* Your portion of payment for office services is due at the time of service.

* Your insurance policy is a contract between you and your insurance company. As a courtesy, we will file your insurance claim for you, and you agree to have your insurance company pay the doctor directly. If your insurance company does not pay the practice within 60 days, the patient or guardian seeking care for a minor, will be responsible for payment of services.

* Please honor our 24 hour reschedule notice, as there is a charge for broken appointments. Repetitive broken or cancelled appointments and/or non-compliance may result in transfer of your care to an alternative practice.

* We have made prior arrangements with insurers and other health plans to accept an assignment of benefits. We will bill those plans with which we have an agreement and will require you to pay the co-pay/co-insurance/deductible at the time of the service. Your upfront portion will be calculated based on your insurance benefit/limits and our negotiated fee agreement with your carrier. If your are seeing our doctors on an 'Out of Network' basis, you will be subject to those out of network rates.

* Not all services are a "covered" benefit in all insurance policies. Some plans even impose a waiting period before covering services. In the event your plan determines a service to be "not covered/pre-existing," or you do not have an authorization, you will be responsible for the complete charge. We will attempt to verify benefits for some specialized services; however, you remain responsible for charges to any service rendered. Patients are encouraged to contact their plans for clarification of benefits prior to services rendered.

* Pre-scheduled Surgical procedures require pre-payment. Your deductible/co-insurance/co-pay for this procedure is due at the pre-operative appointment. For other services provided in the hospital, we will bill your health plan. Any balance due is your responsibility.

*We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in managing your account.

* PAST DUE accounts are subject to collection proceedings. All fees including , but not limited to collection fees, attorney fees and court fees shall become your responsibility in addition to the balance due this office.

* There is a service fee of $25.00 for all returned checks. Upon an NSF or CLOSED ACCOUNT occurrence, all future remittance will need to be in other forms of payment. Restitution of "Theft-by-Check" will be requested from the District Attorney's Office.


* I hereby assign all Medical benefits directly to North Star Foot and Ankle Associates for the payment of any services rendered. I also authorize release of medical records necessary to process my health claims. I fully understand that in the event my insurance company does not pay for the services I received, I will be financially responsible for payment.

* We are dedicated to providing the best possible care and service to you and regard your complete understanding of our policies as an essential element of your care and treatment. If you have any questions, please discuss them with our front office staff.

I acknowledge that I was provided a link to the HIPAA Notice of Privacy Practices and that I have read (or had the opportunity to read if I so chose) and understand the Notice.