Patient Sign-in

Patient Registration Form

Patient Sign-in
New patient Registration
Medical History
Medical history

Welcome to Colorado Foot + Ankle Sports Medicine!

Thank you for selecting our office for your foot and ankle health care needs. We have prepared this packet of information and patient forms in order to help make your visit a convenient and pleasant experience.
Prior to your appointment, please contact your insurance company to clarify your coverage requirements.
When you come for your appointment, please bring the following:
(Do not send prior to you appointment)
  • Written referral (If required by your insurance company)
  • Government issued photo ID
  • Medical insurance Card
  • Completed Registration Form
  • Completed History Form
  • Completed and signed Financial Policy Form
  • Completed and signed Privacy Statement Form
  • Previous X-rays and medical records, if applicable
  • Shoes (bring a sample of the more common shoes that you wear –including athletic and walking shoes)
Note: As you will be receiving advice on the proper shoes for your feet, we recommend that you not purchase any new shoes before your visit.
Please be prepared to pay for the following at the time of your visit:
  • Co-Payment (If applicable)
  • Deductible (If not fully paid for this year)
  • If no insurance, the full cost of the visit
  • Upon Check-in, please allow 15 minutes for patient registration processing.
Our staff is here to help you in whatever manner we can. We look forward to serving you in the near future.
A courtesy email will be sent for appointments scheduled out 3 business days or more in advance. As a courtesy to other patients who are waiting to get in, please call at least 24 hours in advance if you must cancel your appointment. We reserve the right to charge for missed appointments.

Patient Registration( * mandatory to fill )

Is the Patient Under 18(Minor)?*
Yes
No

Guardian Information

Please tell us how you choose us to provide your foot & ankle care:

Please select below

Do You Have Primary Insurance?
Yes No
Do You Have Secondary Insurance?
Yes No
I have read the above choices

Primary Insurance Company( * mandatory to fill )

POLICY HOLDER : SELF OTHER
Do you need a referral to see a specialist?
Yes
No

Secondary Insurance Company( * mandatory to fill )

POLICY HOLDER : SELF OTHER
Military
Yes
No
Do you need a referral to see a specialist?
Yes
No

Accident/Injury

Are you being seen for a work related injury?
Yes
No
Type
Labour & Industry
Self-Insured
Auto
Other
Has a claim been filed?
Yes
No
RELEASE OF BENEFITS INFORMATION
I authorized my insurance benefits to be paid directly to the doctor. I understand that the doctor’s office will bill my insurance as a courtesy and that I am responsible for all co-pays, deductibles, and non-covered services. I authorize the release of any information required to process my claims.
SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

Medical History

This history form provides us with information to help us meet your healthcare needs. Please complete this form answering each question. This is a confidential part of your medical record and will be kept in this office.


Yes No
Check all treatment(s) received for this condition
Past Medical History
Anemia
Yes
No
Angina
Yes
No
Arthritis
Yes
No
Asthma
Yes
No
Bad teeth
Yes
No
Bladder infection
Yes
No
Bladder problems
Yes
No
Blood clots
Yes
No
Cancer
Yes
No
Depression
Yes
No
Diabetes
Yes
No
Emphysema
Yes
No
Epilepsy
Yes
No
Glaucoma
Yes
No
Gout
Yes
No
Heart attack
Yes
No
Heart arrhythmia
Yes
No
High blood pressure
Yes
No
Kidney stones
Yes
No
Liver disease/hepatitis
Yes
No
Psychiatric treatment
Yes
No
Stomach ulcers
Yes
No
Stroke
Yes
No
Thyroid disorders
Yes
No
Tuberculosis
Yes
No
Other
Yes
No
Previous Surgeries
Yes
No
Family History
Is there a family history of arthritis, heart disease, stroke, or cancer?
No
Unknown
Yes
I have answered all the above questions

Financial Policy

This is an agreement between Colorado Foot + Ankle Sports Medicine, as creditor, and the Patient/Debtor named on this form.

In this agreement the words, “you”, “your”, and “yours” mean the Patient/Debtor. The word “account” means the account that has been established in your name to which charges are made and payments credited. The words “we”, “us”, and “our” refer to Colorado Foot + Ankle Sports Medicine.

By executing this agreement, you are agreeing to pay for all services that are received.

Monthly Statement: If you have a balance on your account, we will send you a monthly statement. It will show separately the previous balance, any new charges to the account, the finance charge, if any, and any payments or credits applied to your account during the month.

Payments: Unless other arrangements are approved by us in writing, the balance on your statement is due and payable when the statement is issued, and is past due if not paid by the due date on your statement.

Co-Payments, Deductibles and Balances are required as services are rendered.

Charges to Account: We shall have the right to cancel your privilege to make charges against your account at any time. Future visits would then need to be paid at the time of service.

Required payments: Any co-payments required by an insurance company must be paid at the time of service. Because this is an insurance requirement, we cannot bill you for these.

SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

By signing this agreement, you agree to all the terms and conditions contained herein and the agreement will be in full force and effect.

Missed Appointment Fee: Any patient who does not show up for an appointment, or cancels with less than 24 hours notice, a $50 fee will be charged. We reserve the right to increase this fee without notice. This fee must be paid before a new appointment is scheduled. Patients with three missed appointments will be asked to transfer their records to another doctor.

SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

By signing this agreement, you agree to all the terms and conditions contained herein and the agreement will be in full force and effect.

Contracted Insurance: If we are contracted with your insurance we must follow our contract and their requirements. If you have a co-pay or deductible, you must pay that at the time of service. It is the insurance company that makes the final determination of your eligibility. If your insurance company requires a referral and/or preauthorization, you are responsible for obtaining it. Failure to obtain the referral and/or preauthorization may result in a lower payment from the insurance company.

Non-contracted Insurance:Insurance is a contract between you and your insurance company. We are NOT a party to this contract, in most cases. We will bill your primary insurance company as a courtesy to you. Although we must ask for payment in full at the time of service. Should your insurance company return payment a refund will be issued to you less any remaining balance. If your insurance company requires a referral and/or preauthorization, you are responsible for obtaining it. Failure to obtain the referral and/or preauthorization may result in a lower payment from the insurance company.

Divorce: In case of divorce or separation, the party responsible for the account prior to the divorce or separation remains responsible for the account. After a divorce or separation, the parent authorizing treatment for a child will be the parent responsible for those subsequent charges. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent’s responsibility to collect from the other parent.

Finance Charge: A finance charge will be imposed on each item of your account which has not been paid within thirty (30) days of the time the item was added to the account. The FINANCE CHARGE will be computed at the rate of one percent (1.5%) per month or an ANNUAL PERCENTAGE RATE of twelve (12%) percent. The finance charge on your account is computed by applying the periodic rate (1.5%) to the “overdue balance” of your account. The “overdue balance” of your account is calculated by taking the balance owed thirty (30) days ago, and then subtracting any payments or credits applied to the account during the time, but not to exceed the maximum rate permitted by law."

Past due accounts: If your account becomes past due, we will take necessary steps to collect this debt. If we have to refer your account to a collection agency, you agree to pay all the collection costs which are incurred. If we have to refer collection of the balance to a lawyer, you agree to pay all lawyer’s fees which we incur plus all court costs. In case of suit, you agree the venue shall be Douglas County, Colorado.

Returned Checks: There is a fee (currently $25.00) for any checks returned by the bank.

Credit History:You give us permission to check your credit and employment history and to answer questions about your credit experience with us. We have the option to report your account status to any credit reporting agency such as a credit bureau.

Transferring of Records:You will need to request in writing, and pay a reasonable copying fee if you want to have copies of your records sent to another doctor or organization. The amount of the fee is dependent on the number of pages we need to copy. You authorize us to include all relevant information, including your payment history. If you are requesting your records to be transferred from another doctor or organization to us, you authorize us to receive all relevant information, including your payment history.

Waiver of Confidentiality:You understand if this account is submitted to an attorney or collection agency, if we have to litigate in court, or if your past due status is reported to a credit reporting agency, the fact that you received treatment at our office may become a matter of public record and you consent to such disclosure.

Worker Compensation:We require written approval/authorization by your employer and/or worker’s compensation carrier prior to your initial visit. If your claim is denied, you will be responsible for payment in full.

Personal Injury:If you are being treated as part of a personal injury lawsuit or claim, we require verification from your attorney prior to your initial visit. In addition to this verification we require that you allow us to bill your health insurance. In the absence of insurance, other financial arrangements may be discussed. Payment of the bill remains the patient’s responsibility.

NOTICE OF PRIVACY PRACTICES —ACKNOWLEDGEMENT

We keep a record of the health care services we provide you. You may ask to see and copy that record. You may also ask to correct that record. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so. For a summary or full privacy practice notice, please contact Jennifer Piper, Privacy Officer.

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.

By my signature below I acknowledge receipt of the Notice of Privacy Practices.
In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual’s office instead of the individual’s home.
I wish to be contacted in the following manner (check all that apply):

I consent to the use or discloser of my protected health information by Kevin J Blue, D.P.M. for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of Kevin J Blue, D.P.M.

I understand that diagnosis or treatment of me by Dr. Blue, and Associates may be conditioned upon my consent as evidenced by my signature on this document.
I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or health care operations of the practice. Dr. Blue, and Associates are not required to agree to the restriction that I request. However, If Dr. Blue, D.P.M., agrees to a restriction that I request, the restriction is binding on Dr. Blue, D.P.M., and Associates.
I have the right to revoke this consent, in writing, at any time, except to the extent that Dr. Blue, and Associates or Kevin Blue, D.P.M. has taken action in reliance on this consent.
My "protected health information" means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.
SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )
Thank you for visiting Colorado Foot + Ankle. We want your visit to be pleasant and comfortable. Please help us by completing this form

Welcome to Colorado Foot + Ankle Sports Medicine!

Thank you for selecting our office for your foot and ankle health care needs. We have prepared this packet of information and patient forms in order to help make your visit a convenient and pleasant experience.
Prior to your appointment, please contact your insurance company to clarify your coverage requirements.
When you come for your appointment, please bring the following:
(Do not send prior to you appointment)
  • Written referral (If required by your insurance company)
  • Government issued photo ID
  • Medical insurance Card
  • Completed Registration Form
  • Completed History Form
  • Completed and signed Financial Policy Form
  • Completed and signed Privacy Statement Form
  • Previous X-rays and medical records, if applicable
  • Shoes (bring a sample of the more common shoes that you wear –including athletic and walking shoes)
Note: As you will be receiving advice on the proper shoes for your feet, we recommend that you not purchase any new shoes before your visit.
Please be prepared to pay for the following at the time of your visit:
  • Co-Payment (If applicable)
  • Deductible (If not fully paid for this year)
  • If no insurance, the full cost of the visit
  • Upon Check-in, please allow 15 minutes for patient registration processing.
Our staff is here to help you in whatever manner we can. We look forward to serving you in the near future.
A courtesy email will be sent for appointments scheduled out 3 business days or more in advance. As a courtesy to other patients who are waiting to get in, please call at least 24 hours in advance if you must cancel your appointment. We reserve the right to charge for missed appointments.
Patient Information

Personal Details

Title: First Name: Last Name: Middle Initial: Gender: Preferred Name: Date Of Birth: Billing Address City State Zip Primary Phone Social Security Number Occupation Secondary Phone Email Employer Work# Marital Status Emergency Contact Phone#
Is the Patient Under 18( Miner )? Yes No

Guardian Details

First Name: Last Name: Phone#: Work#: Employer#:
Please tell us how you choose us to provide your foot & ankle care:
Referred by: Clinic Name/Location: Primary Care Physician: Clinic Name/Location:

Please select below:

Are You Married? Yes No

Primary Insurance Information

First Name of insured: Last Name of insured: Middle initial: Relationship to patient: Insured D.O.B: SS#:
Do you need a referral to see a specialist? Yes No
Co-Pay$:
Do You have Primary Insurance? Yes No

Secondary Insurance Information

First Name of insured: Last Name of insured: Middle initial: Relationship to patient: Insured D.O.B: SS#:
Military? Yes No
Branch
Do you need a referral to see a specialist? Yes No
Co-Pay$:
Do You have Secondary Insurance? Yes No

Accident/Injury

Are you being seen for a work related injury? Yes No
If yes, please complete the section below
Date:
Type
Labour & Industry
Self-Insured
Auto
Other
Specify, If Other?
Has a claim been filed? Yes No
Claim# Where?
Name of Adjuster/Agent Phone# Address City Zip Cause of Injury
RELEASE OF BENEFITS INFORMATION
I authorized my insurance benefits to be paid directly to the doctor. I understand that the doctor’s office will bill my insurance as a courtesy and that I am responsible for all co-pays, deductibles, and non-covered services. I authorize the release of any information required to process my claims.
 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS
Medical History

This history form provides us with information to help us meet your healthcare needs. Please complete this form answering each question. This is a confidential part of your medical record and will be kept in this office.

Patient Name What condition/body part(s) are you being seen for today? Onset Date
Previous treatment for this condition? Yes No
Treatment by Date treated Where treated?
Check all treatment(s) received for this condition
Anti-inflammatories X-rays Hospitalization Pain medication
MRI Physical Therapy Injection Bone scan
Fracture to put Surgery EMG back in place
Anemia
Yes
No
Year:
Angina
Yes
No
Year:
Arthritis
Yes
No
Year:
Asthma
Yes
No
Year:
Bad teeth
Yes
No
Year:
Bladder infection
Yes
No
Year:
Bladder problems
Yes
No
Year:
Blood clots
Yes
No
Year:
Cancer
Yes
No
Year:
Depression
Yes
No
Year:
Diabetes
Yes
No
Year:
Emphysema
Yes
No
Year:
Epilepsy
Yes
No
Year:
Glaucoma
Yes
No
Year:
Gout
Yes
No
Year:
Heart attack
Yes
No
Year:
Heart arrhythmia
Yes
No
Year:
High blood pressure
Yes
No
Year:
Kidney stones
Yes
No
Year:
Liver disease/hepatitis
Yes
No
Year:
Psychiatric treatment
Yes
No
Year:
Stomach ulcers
Yes
No
Year:
Stroke
Yes
No
Year:
Thyroid disorders
Yes
No
Year:
Tuberculosis
Yes
No
Year:
Other
Yes
No
Year:
Previous Surgeries
Yes
No
List procedure and date performed
Family History
Is there a family history of arthritis, heart disease, stroke, or cancer?
No
Unknown
Yes
Condition and relative
Weight Height Shoe Size
Patient Name
Social History
Please answer each of the following
Occupation How many years?
Caffeine
Yes
No
How much?:
Drugs
Yes
No
How much?:
Tobacco
Yes
No
How much?:
Alcohol
Yes
No
How much?:
Allergies
Yes
No
List all known allergies
Current Medications
Yes
No
Medications Dosage
Review of Systems
Check all condition and symptoms that you currently have
General
Fever Chills Weight loss Weight gain
Eyes
Blurred Vision Double vision Poor vision Glasses
Ears/nose/throat
Ringing in Ears Sinus congestion Hearing loss Sore throat
Heart
Chest Pain Irregular heart beat Palpitations Other
Lungs
Cough Shortness of breath Difficulty breathing Other
Intestinal
Upset Stomach Bloody stools Constipation Diarrhea
Urinary
Burning Frequent urination Incontinence Other
Musculoskeletal
Joint pain Muscle weakness Joint stiffness Other
Skin
Rashes Sores Masses Scars
Neurological
Tremors Numbness Poor balance Dizziness
Psychiatric
Depression Mood swings Anxiety Other
Endocrine
Hair loss Excessive thirst Fatigue Other
Blood/Lymphatic
Leg swelling Bleeding tendency Bruise easily Other
OB/GYN
Pregnant Birth control pills Hormone therapy Menopausal
Additional Comments
 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

Financial Policy

This is an agreement between Colorado Foot + Ankle Sports Medicine, as creditor, and the Patient/Debtor named on this form.

In this agreement the words, “you”, “your”, and “yours” mean the Patient/Debtor. The word “account” means the account that has been established in your name to which charges are made and payments credited. The words “we”, “us”, and “our” refer to Colorado Foot + Ankle Sports Medicine.

By executing this agreement, you are agreeing to pay for all services that are received.

Monthly Statement: If you have a balance on your account, we will send you a monthly statement. It will show separately the previous balance, any new charges to the account, the finance charge, if any, and any payments or credits applied to your account during the month.

Payments: Unless other arrangements are approved by us in writing, the balance on your statement is due and payable when the statement is issued, and is past due if not paid by the due date on your statement.

Co-Payments, Deductibles and Balances are required as services are rendered.

Charges to Account: We shall have the right to cancel your privilege to make charges against your account at any time. Future visits would then need to be paid at the time of service.

Required payments: Any co-payments required by an insurance company must be paid at the time of service. Because this is an insurance requirement, we cannot bill you for these.

Initial:

 

By signing this agreement, you agree to all the terms and conditions contained herein and the agreement will be in full force and effect.

Missed Appointment Fee: Any patient who does not show up for an appointment, or cancels with less than 24 hours notice, a $50 fee will be charged. We reserve the right to increase this fee without notice. This fee must be paid before a new appointment is scheduled. Patients with three missed appointments will be asked to transfer their records to another doctor.

Initial:

 

By signing this agreement, you agree to all the terms and conditions contained herein and the agreement will be in full force and effect.

Responsible Party (If not Pateint)

Contracted Insurance: If we are contracted with your insurance we must follow our contract and their requirements. If you have a co-pay or deductible, you must pay that at the time of service. It is the insurance company that makes the final determination of your eligibility. If your insurance company requires a referral and/or preauthorization, you are responsible for obtaining it. Failure to obtain the referral and/or preauthorization may result in a lower payment from the insurance company.

Non-contracted Insurance:Insurance is a contract between you and your insurance company. We are NOT a party to this contract, in most cases. We will bill your primary insurance company as a courtesy to you. Although we must ask for payment in full at the time of service. Should your insurance company return payment a refund will be issued to you less any remaining balance. If your insurance company requires a referral and/or preauthorization, you are responsible for obtaining it. Failure to obtain the referral and/or preauthorization may result in a lower payment from the insurance company.

Divorce:In case of divorce or separation, the party responsible for the account prior to the divorce or separation remains responsible for the account. After a divorce or separation, the parent authorizing treatment for a child will be the parent responsible for those subsequent charges. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent’s responsibility to collect from the other parent.

Finance Charge:A finance charge will be imposed on each item of your account which has not been paid within thirty (30) days of the time the item was added to the account. The FINANCE CHARGE will be computed at the rate of one percent (1.5%) per month or an ANNUAL PERCENTAGE RATE of twelve (12%) percent. The finance charge on your account is computed by applying the periodic rate (1.5%) to the “overdue balance” of your account. The “overdue balance” of your account is calculated by taking the balance owed thirty (30) days ago, and then subtracting any payments or credits applied to the account during the time, but not to exceed the maximum rate permitted by law."

Past due accounts:If your account becomes past due, we will take necessary steps to collect this debt. If we have to refer your account to a collection agency, you agree to pay all the collection costs which are incurred. If we have to refer collection of the balance to a lawyer, you agree to pay all lawyer’s fees which we incur plus all court costs. In case of suit, you agree the venue shall be Douglas County, Colorado.

Returned Checks:There is a fee (currently $25.00) for any checks returned by the bank.

Credit History:You give us permission to check your credit and employment history and to answer questions about your credit experience with us. We have the option to report your account status to any credit reporting agency such as a credit bureau.

Transferring of Records:You will need to request in writing, and pay a reasonable copying fee if you want to have copies of your records sent to another doctor or organization. The amount of the fee is dependent on the number of pages we need to copy. You authorize us to include all relevant information, including your payment history. If you are requesting your records to be transferred from another doctor or organization to us, you authorize us to receive all relevant information, including your payment history.

Waiver of Confidentiality:You understand if this account is submitted to an attorney or collection agency, if we have to litigate in court, or if your past due status is reported to a credit reporting agency, the fact that you received treatment at our office may become a matter of public record and you consent to such disclosure.

Worker Compensation:We require written approval/authorization by your employer and/or worker’s compensation carrier prior to your initial visit. If your claim is denied, you will be responsible for payment in full.

Personal Injury:If you are being treated as part of a personal injury lawsuit or claim, we require verification from your attorney prior to your initial visit. In addition to this verification we require that you allow us to bill your health insurance. In the absence of insurance, other financial arrangements may be discussed. Payment of the bill remains the patient’s responsibility.

NOTICE OF PRIVACY PRACTICES —ACKNOWLEDGEMENT

We keep a record of the health care services we provide you. You may ask to see and copy that record. You may also ask to correct that record. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so. For a summary or full privacy practice notice, please contact Jennifer Piper, Privacy Officer.

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.

By my signature below I acknowledge receipt of the Notice of Privacy Practices.

In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual’s office instead of the individual’s home.

I wish to be contacted in the following manner (check all that apply):

I consent to the use or discloser of my protected health information by Kevin J Blue, D.P.M. for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of Kevin J Blue, D.P.M.

I understand that diagnosis or treatment of me by Dr. Blue, and Associates may be conditioned upon my consent as evidenced by my signature on this document.
I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or health care operations of the practice. Dr. Blue, and Associates are not required to agree to the restriction that I request. However, If Dr. Blue, D.P.M., agrees to a restriction that I request, the restriction is binding on Dr. Blue, D.P.M., and Associates.
I have the right to revoke this consent, in writing, at any time, except to the extent that Dr. Blue, and Associates or Kevin Blue, D.P.M. has taken action in reliance on this consent.
My "protected health information" means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.
 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS
Relationship to Client Printed name if signed on behalf of the patient

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