We are excited to announce our new addition to the team, Tasneem Meghani, DPM

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

Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input





Invalid Input

*This information is requested due to Healthcare Reform laws dictated by Congress.

Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input





Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
































































Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input

Social History

Invalid Input

 

Invalid Input
Invalid Input

 

Invalid Input

 

Invalid Input

 

Invalid Input
Invalid Input
Invalid Input

Family History

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

Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input

Insurance Information

Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input

Emergency Contact

Invalid Input
Invalid Input
Invalid Input
Invalid Input

Responsible Party (if minor patient)

Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
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. 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 Advanced Foot Specialists (AFS) as my assignee. I instruct my health care benefits plan administrator, i.e. PLAN to pay AFS directly for all professional and medical services provided by AFS through the means of electronic funds transfer(s) (EFT) or by check(s) made payable to and mailed to AFS. I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS CLAIMS.
Invalid Input
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.
Invalid Input
I acknowledge that I was provided a copy of the Notice of Privacy Practices for Advanced Foot Specialists and I have read (or had the opportunity to read if I so choose) and understood the Notice.

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. Advanced Foot Specialists 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.

Invalid Input

 

Connect With Us

scroll to top