KEY FORMS

• New Patient Packet - 6 pages (Click to download PDF)*

WELCOME NEW PATIENTS!

Please come to the office at least 30 minutes prior to your scheduled appointment so that we can complete the necessary paperwork. If you have previous x-rays, etc. please bring them with you or have them sent to us in advance. Continue reading for details….

TO DOWNLOAD NEW PATIENT FORM

To save yourself time registering as a new patient, you can download and print out a blank copy of our Patient Form. Complete it at home and bring it with you to the office to save time registering.

Instructions to download:

Click on the link below to access the New Patient Form. After you click the link, a browser window will open. After it opens, click on the 'PRINT' icon on your browser. After the form prints, fill it out and bring it with you to the office. Completing the New Patient Information Form will save you time on your initial visit!

• New Patient Packet - 6 pages (Click to download PDF)*

RADIOGRAPHIC STUDIES (X-rays, MRI's, CT Scans, etc.)

• If this is your first time being seen by Dr. Leavitt for your foot/ankle condition, we may take x-rays in our building.



• If you are coming for a second opinion or further consultation, the doctor needs to review your prior X-rays, CT scans, MRI's, Myelograms, bone scans, blood studies or prior consultation findings. You should arrange to bring these with you for your first appointment. To ensure the films and reports are available the day of the appointment, we advise patients to contact the test facility to pick up and hand-carry the films to the appointment. Please be advised that some facilities require pick-up notification several days in advance.

INSURANCE INFORMATION

• Please bring ALL insurance cards with you at the time of your appointment.
• If your insurance plan is an HMO or managed care plan, the patient is responsible for obtaining a referral from your primary care physician.



• Referrals must be received in our Brookline office prior to the appointment. You may call in the referral number to 617-277-3800 and paper referrals may be faxed to 617-277-3808. All paper referals must also be mailed to our central office located in Brookline.



• Co-Payments are accepted at the time of your appointment.



• If the reason for your visit is work or motor vehicle accident related you must have the name of the insurance carrier, claim number, adjuster name and telephone number the day of the appointment.

DISABILITY FORMS

There is no charge for the first request for the completion of disability forms however, any additional requests will be subject to an administrative fee of $5.00 or more. Payment and a HIPPA compliant authorization form must accompany each request prior to the release of any information.

PATIENT PRIVACY

• Patient Privacy Policy*

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