CONTACT APPOINTMENTS DIRECTIONS
Home

Patient Information Form

Patient Information Form

1 Step 1
2 Step 2
3 Step 3
4 Step 4

Patient Information

How did you hear about our practice/ whom may we thank for referring you?

Spouse/ Parent/ Guardian Information

Emergency Contact (If Different From Guarantor)

Pharmacy Information

I hereby authorize Dr. Charles Baik and his associates to examine, photograph, administer treatment, and to perform such minor operative procedures as may be deemed necessary in the diagnosis and/or treatment of my foot/ankle problem.


I assign the right to payment for all medical directly to Dr. Charles Baik in consideration for medical services and supplies provided pursuant to my health insurance plan.


I give consent to Dr. Baik to release medical information to other healthcare providers for the purpose of treatment, when necessary for my care. I give consent to Dr. Baik to send medical information, as necessary to my insurance plan. I agree that a photocopy Of this form may be used in lieu of the original.


I certify the patient information form is true and correct to the best ofmy knowledge. I will notiö' you of any changes in my health status or the above information.

Use your mouse or finger to sign in the box below.

Patient Health History

Review of Symptoms (Please Check if Any of the Following Currently Exist)

Allergies

Medications: Are You Taking Any (Prescription, Birth Control Pills, or Over-The-Counter)? if Yes, What Are They? (Please Include Dosage and Strength if Known)

Medical History: Please Check if Any of the Following Problems Exist or Have Occured in the Past

Family History

Financial Policy

Our goal is to maintain a good physician-patient relationship through clear communication. please review this policy carefully and initial each section.

Financial Responsibility

Use your mouse or finger to sign in the box below.

• You are responsible for all co-payments, deductibles, coinsurance, and non-covered services as determined by your insurance plan.

• Co-payments are due at the time of service.

• Balances are due within 10 business days after receiving your bill.

• Accounts unpaid after 90 days without arrangements may be sent to collections.

• We accept cash, checks, Visa, and MasterCard.

• A $25 fee applies to returned checks.

• If you have trouble paying, please contact us promptly—payment arrangements may be available.

Insurance

Use your mouse or finger to sign in the box below.

We bill your insurance as a courtesy; however, payment is ultimately your responsibility if your insurer does not pay due to inaccurate/untimely information or claim denial

No-Show & Late Cancellation policy

Use your mouse or finger to sign in the box below.

• If you cannot keep this or any other appointment, please advise us as early as possible.

• If you do not call to cancel or re-schedule your appointment within 24 hours of the appointment time, you may be charged $50.00.

• We reserve the right not to reschedule patients who have multiple cancellations.

Acknowledgment

I have read, understand, and agree to comply with this policy. I accept responsibility for any balance due.

Use your mouse or finger to sign in the box below.

**"A holder of this medical debt contract is prohibited by Section 1785.27 of the Civil Code from furnishing any information related to this debt to a consumer credit reporting agency. In addition to any other penalties allowed by law, if a person knowingly violates that section by furnishing information regarding this debt to a consumer credit reporting agency, the debt shall be void and unenforceable."

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT you MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Your Rights

You have the right to

• Get a copy of your medical record

• Correct your medical record

• Request confidential communication

• Ask us to limit what we share

• Get a list of those we've shared your information with

• Get a copy of this notice

• Choose someone to act for you

•  File a complaint if you believe your privacy rights were violated

Your Choices

You have choices about how we share information as we:

• Tell family and friends about your condition

• Share information in a disaster relief situation

See page 2 for details on each choice.

Our uses and Disclosures

We may use and share your information as we:

• Treat you

• Run our practice

• Bill for your services

• Help with public health and safety issues

• comply with law

• Respond to lawsuits and legal actions

www.hhs.gov/hipaa/for-professionals/privacy/index.html

Your Rights, In Detail

Get an electronic or paper copy of your medical record

• You Can ask to see get a copy of medical record and other health information we have about you. We will provide a copy within 30 days, and may charge a reasonable, cost-based fee.


Ask us to correct your medical record

• You can ask us to correct information you think is incorrect or incomplete. We may say no, but we will tell you why in writing within 60 days.


Request confidential communications

• You can ask us to contact you in a specific way (for example, cell phone only) or send mail to a different address. We will accommodate all reasonable requests.


Ask us to limit what we use or share

• You can ask us to share certain health information for treatment, payment, or operations. We are not required to agree, and may say no if it could affect your care.

• If you pay out-of-pocket in full for a service, you can ask us not to share information about that service with your health insurer. We will agree unless the law requires otherwise.


Get a list of those we've shared your information with

• You can ask an accounting of disclosures made in the last six years (excluding treatment, payment, and operations). The first list each year is free.


Get a copy of this notice

• You can ask for paper copy of this notice at any time, even if you agreed to receive it electronically.


Choose someone to act for you

• If someone has your medical power of attorney or is your legal guardian, they can exercise your rights on your behalf once we verify their authority.


File a complaint

• You may complain to us using the contact information above, or to the U.S. Department of Health and Human Services, Office for Civil Rights, 200 Independence Avenue SW, Washington, D.C. 20201, 1-877-696-6775, www.hhs.gov/hipaa/filing-a-complaint/index.html. We will not retaliate against you for filing a complaint.


Your Choices, In Detail

• Share information with family, close friends, or others involved in your care or payment for care — unless you tell us not to.

• Share information in a disaster relief situation.

We do not use your information for marketing or fundraising, and we do not sell your health information, Any such use would require your written authorization.

If you are unable to tell us your preference (for example, in an emergency), we may share information if we believe it is in your best interest.

Our Uses and Disclosures, In Detail

Treat you

• We use and share your information With Other professionals in your care.


Run our practice

• We use your information to manage your treatment, improve care, and contact you when necessary.


Bill for your services

• We share your information with your health plan so it will pay for the services we provide.


Help with public health and safety issues

• As permitted or required by law — for example, to prevent disease, report suspected abuse or neglect, or reduce a serious threat to health or safety.


Comply with the law

• We will share information about you if state or federal law requires it, including with HHS to confirm compliance with federal privacy law.


Respond to lawsuits and legal actions

• We can share information in response to a court or administrative order, or a subpoena.

Our Responsibilities

• We are required by law to maintain the privacy and security of protected health information.

• We will let you know promptly if a breach occurs that may have compromised your information.

• We must follow the duties and privacy practices described in this notice.

• We will not use or share your information other than as described here unless you tell us in writing that we can. You may withdraw that permission in writing at any time.

Changes to This Notice

We may change the terms of this notice, and the changes will apply to all information we have about you. The revised notice will be available at our office and on our website.

Effective Date and Contact

Effective Date: 9/2/2025

Privacy Contact: (714) 832-7212 info@renewpodatry.com

Acknowledgment of Receipt

I acknowledge that I received (or had the opportunity to review) this Notice of Privacy Practices.

Use your mouse or finger to sign in the box below.

HIPAA

Forms Sent!

Thank you, your form has been received.