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 Oexeman Foot and Ankle, PLLC (OFAPLLC) as my assignee. I instruct my health care benefits plan administrator, i.e. PLAN to pay OFAPLLC directly for all professional and medical services provided by OFAPLLC through the means of electronic funds transfer(s) (EFT) or by check(s) made payable to and mailed to OFAPLLC. 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 Oexeman Foot and Ankle, PLLC 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. Your Podiatry Practice 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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ASSIGNMENT OF BENEFITS AND PAYMENTS

Payment is due at the time of service. Balance unpaid 60 days after services are rendered become the patient's responsibility and will be considered delinquent. A late payment charge will be added to an account if payment is not made within 60 days. The late payment charge is 1 ½ percent per month on charges not paid within 60 days. The payment charge will be billed each month until those charges are paid (at the rate of 18 percent per year) and will appear separately on your regular statement. authorize payment for services rendered to me or my dependents to be paid directly to Stephanie Oexeman, DPM from my insurance company, my attorney, or any other party who may become obligated to pay me any sums. I further authorize the endorsement of my name to any draft containing my name to which you are legally entitled. I understand that all charges incurred are the personal responsibility of the patient/guarantor.Commercial insurance is filed as a courtesy to the patient, and managed care insurance is filed with a contracted carrier. The patient/guarantor is responsible for all residual balances including but not limited to co-pays, deductibles, co-insurance and services or charges not paid by insurance for any reason, after consideration of contractual adjustments. In the event any insurance company, attorney, or other person obligated by contractual agreement to make payment to me for your service charges, refused to make such payment upon demand by you, I hereby assign and transfer to you the cause of action that exists in my favor against such company, attorney, or person and authorize you to prosecute said action either in my name or your name or for you to resolve said claim as you see fit. I understand that I shall continue to remain responsible for any uncollected or unpaid balance on my Account. I hereby direct my attorney not to interfere with or claim any lien upon, any medical payment benefits to which I may be entitled from either my health insurance or medical payment sources. And if any said medical payment checks include my attorney's name, I direct my attorney to sign his name to these checks for the benefit of the medical provider herein. In the event that this account goes into default and our office turns it over to our outside collections agency/attorney for collections, it is accepted and agreed that thirty percent (30%) of the principal amount of the balance due will be added as collection/attorney fees. It is also agreed and accepted that in the event that a lawsuit is filed, you, the patient will be liable for any and all court costs expended whether judgment has been entered or not.
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AUTHORIZATION TO RELEASE INFORMATION

I authorize Stephanie Oexeman, DPM and it's physicians to release any information regarding the medical, dental, mental, alcohol or drug abuse history, treatment including disability related information to any third party payer (including Medicare), or their contracted agents, to validate or determine benefits payable for services rendered to myself or any dependents.
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LATE CANCELLATION/ NO SHOW POLICY

Due to the increased demand for appointment times, Oexeman Foot and Ankle, PLLC implements a Cancellation/No Show Policy. Our concern for seeing patients in a timely manner has prompted us to take these steps. We ask for a 24 hour notice for all cancellations. After TWO (2) no-shows, or late cancellations, and a patient's appointment has been confirmed and the patient fails to keep said appointment, there will be a fee assessed to the amount depending on the type of appointment scheduled; i.e., routine follow up $50.00 or procedure $75.00. Insurance will not cover charges for no-show or late-cancellation fees. Payment of the a no-show, or late cancellation fee, must be made in cash, or a valid credit card before further appointments are allowed.
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Cellular Device OPT - IN Consent Form

By signing this agreement, you specifically request, expressly consent to receive, and authorize Oexeman Foot and Ankle, PLLC, its affiliates, business associates, and service providers to deliver, or cause to be delivered, calls and SMS/text and voice messages to your cell phone, and residential line as applicable, using an automatic telephone dialing system and/ or using an artificial or pre-recorded voice. This could result in charges to you according to your data plan. These calls and messages will be for health care and other purposes including but not limited to, for the purpose of appointment reminders, office closure announcements, and clinic operations. If at any point you change or obtain a new cell phone number, or if you no longer maintain the phone number you originally provided to us, you agree to notify Oexeman Foot and Ankle, PLLC immediately of such change by completing the Cellular Device OPT-Out Consent form fo1· your next visit. If you do not have internet access, you agree to notify Oexeman Foot and Ankle, PLLC immediately of such change in writing at the following address: 2913 North Commonwealth Ave 5th Floor Clinic Chicago, IL 60657, attention: Dr. Stephanie Oexeman, DPM. You agree to provide your full name, address, date of birth in your notification. You may be held liable for failure to do so, as outlined in the following provision. Indemnity Provision - READ CAREFULLY: You agree to indemnify and hold Oexeman Foot and Ankle, PLLC, its officers, agents and employees hann less from any liability, loss or damage, including but not limited to, attorney's fees, they may suffer as a result of claims, demands, costs or judgments against them arising out of alleged violations of the Telephone Consumer Protection Act (TCPA) or similar laws, resulting from autodialed or artificial or pre-recorded voice calls placed to an incorrect or reassigned phone number(s), originally belonging to you or wl1ich you provided to the clinic, but of which you failed to timely notify the Clinic that such number(s) was incorrect or no longer assigned assigned to you. I authorize and expressly consent to receiving calls and/or SMS/text and voice messages delivered to my phone number placed by Oexeman Foot and Ankle, PLLC, its affiliates, associates, and service providers, from an automatic telephone dialing system and/or using an artificial or pre-recorded voice, for healthcare and other purposes, including appointment reminders, office closure announcements, and clinic operations. I agree to notify Oexeman Foot and Ankle, PLLC immediately if I change or obtain a new phone number, or no longer maintain the phone number provided herein, and expressly acknowledge that I may be held liable for failure to do so, as outlined above. I understand that I need not sign this form as a condition to purchase goods or services and that SMS/text messages and voice messages carry certain risks. For example, messages may be sent in unencrypted form. They could be received by others if others have access to my device or if my messages are sent to another device. I understand the risks, and I expressly consent to receiving these messages and ask Oexeman Foot and Ankle, PLLC to communicate with me in this form. If you would like a printable version of this form to bring to the clinic, please contact the office for a signed copy.
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LATE CANCELLATION/ NO SHOW POLICY

Due to the increased demand for appointment times, Oexeman Foot and Ankle, PLLC implements a Cancellation/No Show Policy. Our concern for seeing patients in a timely manner has prompted us to take these steps. We ask for a 24 hour notice for all cancellations. After TWO (2) no-shows, or late cancellations, and a patient's appointment has been confirmed and the patient fails to keep said appointment, there will be a fee assessed to the amount depending on the type of appointment scheduled; i.e., routine follow up $50.00 or procedure $75.00. Insurance will not cover charges for no-show or late-cancellation fees. Payment of the a no-show, or late cancellation fee, must be made in cash, or a valid credit card before further appointments are allowed.
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