Copper Top Foot & Ankle

Poplar Bluff, MO

  • Services
  • New Patients
  • Patient Education
  • Physicians
  • Bill Pay
  • Apply

Forms

Step 1 of 9 - Basic Information

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  • Basic Information

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  • Insurance Information

    We will need a copy of your insurance cards before being seen by the physician
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  • Confidential New Patient Questions

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  • Surgical History

  • OperationDateHospitalSurgeon 
  • Family History

  • Social History

  • ROS

  • MED

  • Notice of Privacy

  • I understand that under the Health Insurance Portability and Accountability Act (HIPAA), I have certain rights to privacy regarding my protected health information. I acknowledge that I have received or have been given the opportunity to receive a copy of your Notice of Privacy Practices. I also understand that this practice has the right to change its Notice of Privacy Practices and that I may contact the practice at any time to obtain a current copy of the Notice of Privacy Practices.
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  • Information and assignment of Benefits

  • I authorize the release of any medical information necessary to process any of my claims. I permit a copy of this authorization to be used in place of the original.
  • I hereby authorize the physicians of this company to apply for benefits on my behalf for covered services rendered by them or by their order. I request that payment from my insurance company be made directly to the physician. I certify that the information I have reported with regard to my insurance coverage is correct. I permit a copy of this authorization to be used in place of the original. This authorization may be revoked be either me or my insurance company at any time.

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Copper Top Foot & Ankle Clinic
2600 Kanell Blvd
Poplar Bluff, Missouri 63901
(573) 785-4546

  • Services
  • New Patients
  • Patient Education
  • Physicians
  • Bill Pay
  • Apply

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