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NEW PATIENTS

We welcome you as a patient to our Podiatry practice in Coeur d’Alene, Idaho. We are grateful that you have chosen us as the health care provider for your feet. Please do not hesitate to discuss any areas of concern. Everyone in this office is a trained professional and works as a team member dedicated to providing you with the finest medical, surgical and rehabilitative treatments for the foot and ankle.

What to Expect at Your First Visit

When you come to our office for your visit, we will need to see your insurance card(s) and your driver’s license (or other valid picture identification). We will scan these into our computer system so that you will only need to present them at your first visit of each year or if your insurance changes. Unless you have already completed the new patient forms, we will ask that you complete those prior to seeing the doctor. One of our Registered Nurses will escort you to a treatment room and will talk to you about your foot or ankle complaint, as well as reviewing your medical history, your family medical history, and your lifestyle. You will need to remove your socks and shoes from both feet, even if your complaint involves only one foot for examination for comparison purposes. The doctor will examine your feet and discuss your concerns and the history of your foot or ankle complaint. If x-rays are needed, they can be performed in our office with results immediately available to the doctor. If you have medical records, x-rays or other diagnostic test results which may be relevant to the reason for your visit, please bring those with you as they may assist the doctor in his assessment, diagnosis or treatment recommendations.

Items to bring to your first appointment

  • Insurance Card(s)
  • Driver’s License or other picture ID
  • New Patient Forms, completed & signed
  • List of prescription & over-the-counter medications
  • Relevant medical records and/or x-rays if available.

New Patient Forms:

PATIENT INFORMATION FORM

Patient Informaton

Employment Information

Spouse Information

Please complete this section if the patient

is not the person responsible for the bill

Emergency Contact Information:

In case of emergency who can our office contact

How did you hear about our office?

FINANCIAL POLICY

As we see patients from many different insurance plans, it is impossible for us to know all the covered benefits, co-pays, and deductibles for each plan. In addition, your insurance company will not guarantee payment to us. While it is our intention to assist you, it is still your responsibility to ensure that all services rendered or bya Dr. Nuñez on you behalf are paid in full.

Patients Without Insurance Coverage

Payment in full at the time of service is expected unless you have worked out a payment plan prior to your visit. Patients on approved payment plan will expected to pay at least 1/2 on the date of service and the remainder in a timely manner.

Orthotics and DME

There may be devices that Dr. Nuñez feels will be of benefit to you depending upon your condition that are not always covered bye insurance plans. If this applies to you, we requiere that the orthotic, brace, etc. is paid for in full upon receipt since we cannot allow returns on these items.

Thank you for reviewing this information carefully. If you have any questions or need to establish a payment plan, please contact our office at (208) 666 - 0605

PATIENT SECURITY

Please list below those that you would like us to be able to provide information to about you care. Without your authorization we will be unable  to provide information about appointments, treatment plan, etc. This for your security and is require by HIPPA. Thank you for you understanding.

ADVANCE DIRECTIVE

If you have a living will, or durable power of attorney for healthcare, you can provide a copy to the staff who will place the documents in your medical record. In Idaho, the Living Will and Durable Power of Attorney for Healthcare are obtained in one document. You may obtain Idaho State Advance Directive forms at:

https://sos.idaho.gov/hcdr/LivingWillDurablePowerOfAttorney.pdf

 

PATIENT HEALTH HISTORY

Personal Information

REVIEWS OF SYSTEMS/MEDICAL HISTORY

HIPAA - NOTICE OF PRIVACY PRACTICES

This summary Notice of Privacy  Practices contains a description of how our office and Dr. Orlando E. Nuñez will protet your health information and your rights as a patient. Please refer to the full notice for further information.

We will use and disclose your health information in order to treat you or to assist other health care providers in treating you. We will also use and disclose your health information in order to obtain payment for our services or to allow insurance companies to process claims for services renderred to you. Finally, we may use and disclose your health information for assessment, licensing, accreditation, and training of students.

We will not use or disclose your health information without your writtend authorization except as stated in the Notice of Privacy Practices Manual.

Patient Rights

As our patient, you have the following rights:

  • To have acces to and/or copies of your health information with a written consent and photo identification.
  • To receive information of certain disclosures we have mde of your health information.
  • To reques restrictions as to how your health information is used or disclosed.
  • To request that we amend your health information.
  • To receive a Notice of Privacy Practices.

If you have any questions, concerns, or complaints regarding our privacy practices, please refer to the HIPAA Privacy manual for the person or persons you may contact.

You have reviewed "Your Rights as a CDA Foot & Ankle Clinic Patient" printed above. Signing below acknowledges the receipt of the written Notice of Patient Rights.

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Click or drag a file to this area to upload.

Insurance Information

I REQUEST THAT PAYMENT OF AUTHORIZED INSURANCE BENEFITS BE MADE EITHER TO ME OR ON MY BEHALF TO DR. ORLANDO E. NUÑEZ DPM, M FOR ANY SERVICES FURNISHED TO ME BY COEUR D´ALENE FOOT & ANKLE CLINIC. I AUTHORIZE AND HOLDER OF MEDICAL INFORMATION ABOUT ME TO RELEAE TO THE CENTERS OF MEDICAR AND MEDICAID SERVICES, FORMERLY THE HEALTH CAR FINANCING ADMINISTRATION AND ITS AGENTS ANY INFORMATION NEEDED TO DETERMINE THESE BENEFITS OR THE BENEFITS PAYABLE FOR RELATED SERVICES.

I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES THAT ARE NOT COVERED BY MY INSURANCE COMPANY.

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REQUEST AN APPOINTMENT

Please call us at (208) 666-0605 or fill out the form below
to submit your information

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