Privacy Practice Consent 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.


I understand that Family Foot Clinic, LLC

(Referred to below as “This Practice”) will use and disclose health information about me. I understand that my health insurance may include information both created and received by This Practice, may be in the form of written or electronic records or spoken words, and may include information about my health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions and similar types of health-related information.

I understand and agree that This Practice may use and disclose my health information in order to:

  • Make decisions about and plan for my care and treatment.
  • Refer to, consult with, coordinate among, and manage along with other health care providers for my care and treatment.
  • Determine my eligibility for health plan or insurance coverage, and submit bills, claims and other related information to insurance companies or others who may be responsible to pay for some or all of my health care.
  • Perform various office, administrative and business functions that support my physician’s efforts to provide me with, arrange and be reimbursed for quality, cost-effective health care.

I also understand that I have the right to receive and review a written description of how This Practice will handle health information about me. This written description is known as Notice of Privacy Practices and describes the uses and disclosures of health information made and the information practices followed by the employees, staff and other office personnel of This Practice, and my rights regarding my health information.

I understand that the Notice of Privacy Practices may be revised from time to time, and that I am entitled to receive a copy of any revised Notice of Privacy Practices. I also understand that a copy or a summary of the most current version of this Practice’s Notice of Privacy Practices, in effect will be in the waiting/reception area.

I understand that I have the right to ask that some, or all, of my health information not be used or disclosed in the manner described in the Notice of Privacy Practices, and I understand that This Practice is not required by law to agree to such requests.

By accepting & entering my name as a digital signature below, I agree that I have reviewed and understand the information above, and that I have received a copy of the Notice of Privacy Practices.