First Time Arrival Checklist - cfac.net

First time Arrival Checklist Items to bring: Registration Form completed Consent to Treat/Acknowledgement of Financial Responsibility/Notice of Privacy Practices Acknowledgement Form Signed Medical History Form completed Vascular/Neurological Screening Form completed if one of the following applies: o Diabetes o Over 65, (50 with diabetes). o Smoke o History of known heart disease Personal Representative Authorization Form completed (optional see form for details). All insurance cards and an identification card with a your photo Up-to-date list of all medications After Arrival : We are required to have you sign an acknowledgement that you have received the Notice of Privacy Practices that was included with this packet. Welcome to Centers For Foot & Ankle Care! Our Mission: The podiatrists at Centers For Foot & Ankle Care are dedicated to providing you the highest quality foot care.

CFAC requires an administrative fee for the retrieval, duplication and transfer of a patient’s medical chart. This fee covers the cost of the duplication and any applicable postage to forward those medical

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