new patients


Thank you for choosing Podiatric Physicians of Louisville as your foot care provider!  If you haven’t already done so, please call us at 502-426-7222 to schedule your appointment. Once you have scheduled an appointment to see us, the next step is to prepare yourself with the necessary information for your visit.

new patient FORMS

You may complete our New Patient forms online below. If you don’t wish to complete this form online, you may download the New Patient Packet and fill it in by hand. To download the packet, scroll down the page to the links.

 
PATIENT INFORMATION
Name *
Name
Please use the name listed on your insurance card
Jr., Sr., II, etc.
You may provide this to us in our office if you do not wish to include it online
Date of Birth *
Date of Birth
Address *
Address
Primary Phone Number *
Primary Phone Number
Secondary Phone Number
Secondary Phone Number
Please include the person's name, relationship to you, and their primary phone number
Please enter the full name of the physician, if possible
Race
Ethnicity
Marital Status
Are You A Student?
Are You Employed?
If applicable
Medicare, Anthem, etc. If you don't have insurance, type SELF PAY
If applicable
AUTHORIZATION TO TREAT / HIPAA / PHONE CONSENT
I hereby authorize professional services rendered by Dr. Larry Ketcherside and / or Dr. Alexander Brewer. In accordance with HIPAA, I have had the opportunity to read and review a copy of the Privacy Practices located in the offices of Podiatric Physicians of Louisville, PSC. I authorize the release of any medical information requested by my insurance company that is acquired during the course of my examination and treatment. I also give permission to Podiatric Physicians of Louisville to share my information with my primary care physician and any other medical facilities and / or physicians to which I may be referred. I give my consent for Podiatric Physicians of Louisville to remind me of my scheduled appointment by using an automated reminder program. I understand that this message may include the physician’s name and the date/time of my appointment. It may be delivered to an answering machine or to anyone who should answer the telephone. I authorize Podiatric Physicians of Louisville to view and scan my insurance cards and photo identification, as well as take a photographic image of my likeness, to ensure proper identification. Original X-Rays are property of this office. Digital copies on discs may be purchased for $2.00 each. I understand that honest and complete answers to each question stated are important to the provision of my medical care and I have answered them to the best of my ability. I have been informed that if I am uncertain about any question on this form, I should ask the doctor of a staff member for assistance.
E-Signature
We will also have you physically sign this when you come into the office
Name of Patient / or Person Authorized to Consent for Patient *
Name of Patient / or Person Authorized to Consent for Patient
Today's Date *
Today's Date
MEDICAL HISTORY
Patient Name
Patient Name
Was this an injury?
PLEASE CHECK ALL THAT APPLY TO YOU
Family History Of:
Do You Smoke?
Do You Drink Alcohol?
If you have a list, we can copy it for you at the office
If you have a list, we can copy it for you at the office
If you have a list, we can copy it for you at the office
I HAVE FILLED OUT THIS MEDICAL HISTORY FORM TO THE BEST OF MY KNOWLEGE
E-Signature
We will also have you physically sign this when you come into the office
Name of Patient / or Person Authorized to Consent for Patient *
Name of Patient / or Person Authorized to Consent for Patient
Today's Date *
Today's Date
ACCEPTANCE OF FINANCIAL RESPONSIBILITY
We will be happy to file your insurance, but will expect monthly payments on your account if there is a remaining balance. We participate in MOST of the major insurance plans in the area. To participate means to accept what the insurance company approves, NOT what they pay. Usually, the patient is responsible for a percentage of what the insurance company approves, or for a co-payment, co-insurance, or deductible amount. It is your responsibility to know what your insurance coverage is as there are multiple plans in the area, and it would be impossible for us to know the details of every plan. Insurance policies that require a referral for a patient to be seen is SOLELY the responsibility of the patient to obtain. The referral is to be obtained from that patient’s Primary Care Physician and is to be received by our office PRIOR to being seen. If a referral has not been obtained prior to your appointment time, you will be rescheduled. However, if you still wish to be seen by the physician without a referral, you will be responsible for payment on that date of service. For any accounts over sixty (60) days old, you will be charged interest at a rate of 1.5% per month. All open accounts will be balance billed. We accept cash and credit cards, as well as checks. There will be a $35.00 charge on all returned checks. You are required to pay any co-payment amount due at the time of your visit. Co-payments are not billable. If you are unable to pay your co-payment, you will be rescheduled. No exceptions. Payment for any over-the-counter products purchased at our office will be due upon checkout on that date of service. We will happily hold an item for you if you are unable to pay for the product upon checkout. You can return at any time for your product with your payment. All appointments that are not cancelled prior to your appointment time will result in a $40.00 No-Show fee. If you are more than ten (10) minutes late to your scheduled appointment time, you will be rescheduled. You agree, in order for us to service your account or to collect any amounts you may owe, we may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending e-mails, using any e-mail address you provide to us. Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automatic dialing device, as applicable. I understand that I am financially responsible for any balance not covered by my insurance carrier. I will ensure that my insurance company pays their responsible charges in a timely manner. Any denied charge is payable within thirty (30) days. I am responsible for any services that have not been approved by my insurance company. I have read the above information and was permitted to ask questions which were answered to my satisfaction.
E-Signature
We will also have you physically sign this when you come into the office
Name of Patient / or Person Authorized to Consent for Patient *
Name of Patient / or Person Authorized to Consent for Patient
Today's Date *
Today's Date

DOWNLOAD THE FORMS

Be sure to fill out the form in its entirety, prior to your appointment, to lessen waiting time during check-in. Click the link below to download the packet.

CLICK HERE TO DOWNLOAD >>

If the New Patient is a minor, please CLICK HERE >>

These forms require a PDF viewer such as Adobe Reader.  If you do not have a PDF viewer installed, please visit the Adobe Reader download page at https://get.adobe.com/reader/


Please bring the following to your appointment:

  • Driver's license / government photo identification

  • All insurance cards

  • New Patient Packet (filled out entirely)

  • A copy of your medication list

  • A list of drug allergies

  • A copy of your surgical history


copays

If your insurance requires a copayment, we will collect it before you are seen by the physician.  Copays cannot be billed.  If you are unable to pay your copay at the time of your appointment, you will be rescheduled.


insurances which require referrals

If your insurance requires a referral to be seen by a specialist, you will need to contact your Primary Care Physician to obtain one.  This must be done before the day of your appointment.  If we do not have a referral for you, we will reschedule your appointment.