Forms
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Welcome to San Luis Podiatry Group
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.
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San Luis Podiatry Group - New Patient Registration Form
Once you've requested an appointment with us, feel free to print this form, fill it out, and bring it with you to save time in our waiting room.
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HIPAA Acknowledgement Receipt
Sign and fax or bring in with New Patient forms. Confirmation that you have received a copy of the HIPAA Privacy Policy.
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Custom Functional Foot Orthotics: Financial information
If custom orthotics are an indicated procedure for you, as determined by our evaluation, the following information covers our fee policy.
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Medical Records Release Authorization
Authorization to release your medical records to another physician.
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Financial Policy
Thank you for choosing us as your podiatric physicians. We are committed to your treatment being successful, as you, the patient, are our first and foremost concern. As part of our service, we try to contain the cost of health care. In an effort to do this, we have implemented a Financial Policy.
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DMV Application for Disabled Person Placard or Plates
For temporary or permanent parking placards, travel parking placards, or disabled person license plates.
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Employee Claim for Disability Insurance benefits
From the Sate of California Employment Development Department.
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Family and Medical Leave Act and California Family Rights Act
FMLA/CFRA Policy and Procedures
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Employee Application for Family Care and Medical Leave
This application is provided for employees to document their request for Family Care and Medical Leave (FML). Any request for FML leave for any purpose and its approval or denial must be properly documented.
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Certification of Health Care Provider for Employee
The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA protections because of a need for leave due to a serious health condition to submit a medical certification issued by the employee’s health care provider.
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Do you qualify for a Diabetic Shoe through Medicare?
The information provided will help you verify whether or not you are eligible to receive Therapeutic Diabetic Extra Depth footwear through Medicare and other participating insurances. This program is designed to help reduce the incidence of foot ulcerations that could lead to foot amputations.
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Medicare's Therapeutic Shoe Bill
According to the American Diabetes Association, there are approximately 16 million Americans with diabetes. Unfortunately, this number continues to grow. Twenty-five percent of persons with diabetes develop foot problems related to the disease. Recognizing this problem, Congress approved the Medicare Therapeutic Shoe Bill, helping thousands of persons with diabetes obtain protective footwear and inserts.
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Statement of Certifying Physician for Therapeutic Shoes
Medicare requires that your primary care physician (doctor treating your diabetes) complete this form.
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Advance Beneficiary Notice of Noncoverage
Medicare does not pay for everything, even some care that you or your health care provide have good reason to think you need.
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Statement Of Certifying Physician and Prescription
To be completed by the physician monitoring the diabetic condition.
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FSCAN Screening Diabetics
Please complete this form prior to your FSCAN Screening visit.
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FSCAN Diabetic Screening Waiver
Please complete this form prior to your FSCAN Screening visit.