Patient Intake Forms

1. Assignment of Benefits, Financial Responsibility & Authorization to Release Information for Billing

Assignment of Insurance Benefits. I hereby assign and authorize direct payment to Fallbrook Podiatry Inc. (Dr. Grigoriy N. Patish, D.P.M.) of any and all insurance benefits, Medicare benefits, Medi-Cal benefits, or benefits payable under any other third-party health plan for services rendered to me. This assignment applies to all current and future claims arising from treatment provided by this practice, unless I revoke this assignment in writing.

Financial Responsibility. I understand and agree that I am personally responsible for all charges incurred for services provided to me by Fallbrook Podiatry Inc., regardless of insurance coverage. This includes, but is not limited to, copayments, coinsurance, deductibles, non-covered services, services denied by my insurance carrier, and any balance remaining after insurance payment. I understand that my insurance policy is a contract between me and my insurance company, and that Fallbrook Podiatry Inc. is not a party to that contract.

Good Faith Estimate Notice (No Surprises Act). If I am uninsured or choose to self-pay, I understand that I have the right to receive a Good Faith Estimate of the expected charges for scheduled services, as required by federal law (42 USC §300gg-111). I may request a Good Faith Estimate at any time before or after receiving services.

Authorization to Release Information for Billing. I authorize Fallbrook Podiatry Inc. to release any medical information — including diagnosis, treatment records, clinical notes, and diagnostic imaging results — necessary to process insurance claims, obtain preauthorization, or determine benefit eligibility. This authorization permits disclosure to my insurance company, Medicare, Medi-Cal, workers’ compensation carriers, or any other entity responsible for payment of my healthcare services.

Collection Costs. In the event that my account becomes past due and is referred to a collection agency or attorney for collection, I agree to pay all reasonable collection costs, attorney’s fees, and court costs incurred in the collection effort, to the extent permitted by California law.

Accuracy of Information. I certify that all personal, demographic, and insurance information I have provided on this form is true and correct to the best of my knowledge. I understand that providing false or misleading information may result in denial of coverage, and I agree to notify Fallbrook Podiatry Inc. promptly of any changes to my insurance coverage, address, or contact information.

2. HMO / Managed Care Referral Acknowledgment

Referral Requirement. I understand that if my insurance is an HMO (Health Maintenance Organization) or other managed care plan, I must obtain a valid referral and/or prior authorization from my primary care physician (PCP) before each visit to Fallbrook Podiatry Inc. It is my responsibility — not the responsibility of this office — to verify that a current referral is on file and that the authorization has not expired.

Financial Responsibility Without Valid Referral. If I arrive for an appointment without a valid, current referral or authorization when one is required by my plan, I understand that I will be personally responsible for the full cost of that visit and any services rendered. Fallbrook Podiatry Inc. may, at its discretion, attempt to obtain a referral on my behalf, but is under no obligation to do so and makes no guarantee that such efforts will be successful.

Coordination of Care. I authorize Fallbrook Podiatry Inc. to communicate with my primary care physician and/or referring provider regarding my treatment plan, clinical findings, and ongoing care, as necessary for proper coordination of my healthcare.

3. Appointment Cancellation & No-Show Policy

I understand and agree to the following appointment policies of Fallbrook Podiatry Inc.:

Cancellation Notice. If I need to cancel or reschedule an appointment, I agree to provide at least 24 hours’ advance notice by calling (760) 728-4800. Cancellations made less than 24 hours before the scheduled appointment, or failure to arrive for a scheduled appointment without prior notice (a “no-show”), may result in a no-show fee.

No-Show Fee. A fee of up to $150.00 may be charged for missed appointments or late cancellations. This fee is not billable to insurance and is my personal responsibility. Repeated no-shows may result in discharge from the practice.

Late Arrival. If I arrive more than 15 minutes late for a scheduled appointment, the office may need to reschedule my visit to avoid disrupting the care of other patients.

Emergencies. I understand that genuine emergencies and unavoidable circumstances will be taken into consideration, and that I should contact the office as soon as possible in such situations.

4. Acknowledgment of Receipt — Notice of Privacy Practices (HIPAA)

Federal law (45 CFR §164.520) requires that we provide you with a copy of our Notice of Privacy Practices.

I acknowledge that I have been offered a copy of the Notice of Privacy Practices of Fallbrook Podiatry Inc. (Dr. Grigoriy N. Patish, D.P.M.). This Notice describes how my medical information (Protected Health Information, or “PHI”) may be used and disclosed by Fallbrook Podiatry Inc. for the purposes of treatment, payment, and healthcare operations, as well as other uses and disclosures permitted or required by law. The Notice also explains my rights regarding my medical information, including the right to request restrictions, request communications by alternative means, inspect and obtain copies of my medical records, request amendments, receive an accounting of certain disclosures, and file a complaint with the practice or with the U.S. Department of Health and Human Services if I believe my privacy rights have been violated.

I understand that Fallbrook Podiatry Inc. reserves the right to change the terms of its Notice of Privacy Practices and to make the new provisions effective for all PHI that it maintains. A current copy of the Notice will be posted in the office and is available at www.fallbrookfootdoctor.com.

5. Authorization to Release Medical Records & Information

IMPORTANT: This is a separate HIPAA authorization as required by 45 CFR §164.508 and California Civil Code §56.11.

I hereby authorize Fallbrook Podiatry Inc. (Dr. Grigoriy N. Patish, D.P.M.) to obtain and/or release my medical records and health information — including clinical notes, diagnostic imaging (X-rays), laboratory results, treatment plans, surgical reports, photographs, and pathology or biopsy results — to and from: my referring physician(s) and primary care provider(s), other treating healthcare providers involved in my care, my insurance company, Medicare, Medi-Cal, or other third-party payers, laboratories, imaging centers, hospitals, and surgical facilities, pharmacies (for prescription verification), and legal representatives I have designated in writing.

This authorization does not expire unless I specify an expiration date. I understand that I may revoke this authorization at any time by submitting a written request to: Fallbrook Podiatry Inc., 407 Potter Street, Suite A, Fallbrook, CA 92028. Revocation will not affect any disclosures already made in good-faith reliance on this authorization. Treatment is not conditioned on signing. Once my health information is disclosed to a recipient under this authorization, it may be subject to redisclosure and may no longer be protected by HIPAA or California law.

6. Consent for Communications — Phone, Text, Email & Voicemail

I authorize Fallbrook Podiatry Inc. and its agents to contact me for appointment reminders, follow-up care, billing inquiries, test results, and other healthcare-related communications using any of the following methods:

I understand that these communication methods are not fully secure and that my health information could be seen or heard by others. I accept this risk. I may change my preferences at any time by notifying the office in writing.

7. Informed Consent for Examination, Treatment & Diagnostic Procedures

I, the undersigned patient (or authorized representative), voluntarily consent to examination and treatment by Dr. Grigoriy N. Patish, D.P.M. and/or the clinical staff of Fallbrook Podiatry Inc. I understand that podiatric medicine encompasses the diagnosis, medical, surgical, mechanical, manipulative, and electrical treatment of the human foot, ankle, and tendons that insert into the foot, as well as the nonsurgical treatment of the muscles and tendons of the leg governing the functions of the foot (per California Business & Professions Code §2472).

Scope of This Consent. This consent covers routine outpatient examinations, evaluations, and treatments, which may include but are not limited to: physical examination of the feet, ankles, and lower extremities; X-ray and other diagnostic imaging; diagnostic ultrasound; laboratory testing; administration of local anesthesia; wound care and debridement; injection therapies (corticosteroid, anesthetic, regenerative medicine); nail procedures (including partial or total nail removal); minor in-office surgical procedures; casting, splinting, strapping, and padding; orthotic and prosthetic device fitting and dispensing; prescription of medications; and physical therapy and rehabilitation exercises.

Separate Surgical Consent. I understand that any major surgical procedure will require a separate, procedure-specific informed consent that will be discussed with me in detail prior to surgery, including the nature of the procedure, expected benefits, material risks, alternatives, and risks of refusing the procedure, in accordance with California informed consent law (Cobbs v. Grant, 8 Cal.3d 229; CACI 532-535).

Right to Refuse. I understand that I have the right to refuse any examination, treatment, or procedure at any time. No Guarantee of Results. I understand that medicine is not an exact science and that no guarantee has been made to me regarding the outcome of any examination, treatment, or procedure. Tissue Specimens. I consent to the examination and disposal of any tissue, body parts, or specimens removed during the course of my treatment, including submission to a laboratory for pathological study when deemed medically appropriate.

8. Authorization for Photography, Video & Use in Marketing Materials

THIS IS A VOLUNTARY AUTHORIZATION. YOUR TREATMENT WILL NOT BE AFFECTED IF YOU CHOOSE NOT TO SIGN.

I authorize Dr. Grigoriy N. Patish, D.P.M. and the clinical staff of Fallbrook Podiatry Inc. to take clinical photographs, videos, and/or audio recordings of my feet, ankles, lower extremities, and related areas during the course of my examination and treatment. By signing below, I give my specific, voluntary consent for the Practice to use my photographs, videos, likeness, voice recordings, and/or my patient testimonial (if given) for the Practice’s website (including English and Spanish pages), social media accounts, printed and digital marketing materials, educational presentations, before-and-after case presentations, and internal staff training.

De-Identification Efforts. The Practice will make reasonable efforts to de-identify images by cropping faces and removing identifying features when clinically feasible. However, I understand that certain photographs may make me recognizable, and I accept that risk. No Compensation. I understand that I will not receive any payment for the use of my images or testimonial. Ownership. All photographs, videos, and recordings taken by the Practice are the property of Fallbrook Podiatry Inc.

Digital Replicas. Pursuant to California Civil Code §3344 as amended by SB 683 (2025), this authorization covers only actual photographs and recordings of me and does not authorize the creation of any AI-generated digital replica of my likeness, voice, or identity. Two-Party Recording Consent. I consent to any audio or video recording made in connection with my care pursuant to California Penal Code §632.

Revocation. I may revoke this authorization at any time by submitting a written request to: Fallbrook Podiatry Inc., Attn: Privacy Officer, 407 Potter Street, Suite A, Fallbrook, CA 92028. The Practice is not required to retrieve or delete images already published prior to revocation. Treatment is not conditioned on signing this marketing authorization.

Please initial your choices:

In-Person Verification & Attestation

I, the undersigned, hereby attest that all electronic signatures, initials, and selections on this form were made by me (or by my authorized representative) and accurately reflect my intentions. I have read each section and understand the content, rights, obligations, and authorizations described herein. I am signing this attestation voluntarily and in the presence of a staff member of Fallbrook Podiatry Inc.