Patient Information Form

Your Office Visit

To ensure our office provides quality care, please remember to always bring an updated list of medications, allergies, and previous surgical procedures. Also, please bring your current insurance card along with your copay, if applicable, to facilitate easy payment for your services.

Patient Forms

If you are visiting our office for the first time, or have not been seen within one year, you will need to complete quick and simple forms at or before your upcoming appointment. You may fill out or download all 3 forms located here on this page in the green patient forms box.

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Patient Information







Personal Responsible for Bill (If different than above)




Insurance Information



Referral

How did you hear about us?
(Please check all that apply)

InternetHospital/ERInsuranceDoctorFriend/FamilyOther

PLEASE READ THE FOLLOWING: I hereby give my permission for Dr. Keeler and/or staff of Family Foot Clinic LLC to administer
treatment as deemed necessary in the diagnosis and/or treatment of any podiatric medical condition.

OFFICE POLICIES: All non‐covered cervices are due at the time of service. As a courtesy to me, my insurance claim will be processed
provided all necessary information is presented. I understand that if my insurance company requires that my primary care physician
refer me to Dr. Keeler and I have not obtained that referral, that any charges incurred will be, my responsibility. I also understand
that I must notify Dr. Keeler of any need to pre‐authorize treatment, and I accept responsibility for all charges for which preauthorization
is not obtained. COPAYMENTS ARE DUE AT THE TIME OF SERVICE. Statements are sent out monthly. My account will
be assessed a rebilling charge of $20.00 per month for any balance over 90 days. Balances are not carried over 120 days. If my
insurance company has not paid within that time frame, the balance over 120 days will my responsibility. If payment does not result,
my account will be assigned to collections. I understand that if it becomes necessary to use outside attorney or collection efforts to
bring my account to a paid status I will be charged an additional 33.3% of any unpaid balance at the time of referral for all costs of
collection and/or attorney’s fees. Also, I hereby authorize any insurance benefits to be payable directly to the physician. I am
financially responsible for all non‐covered charges. I also authorize the physician to release any medical information necessary in
processing my insurance claim to my insurance company. A charge of $30.00 will be added to all returned checks. If you are unable
to keep an appointment, we require you to give us 24‐hour notice. There will be a $25.00 charge to all “no show” appointments or
canceled appointments under 24 hours.


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