Patient Forms and Information
To help us prepare for your visit, please fill out the form or forms you
have been directed to complete, and bring them to your appointment.
Patient intake form
Podiatry patient form
Dr. DeFranco’s patients:
Knee evaluation form
Shoulder evaluation form
When you arrive for your appointment, we will make copies of your driver’s
license and insurance card.
Please read this clinic information:
We understand there are times when patients must cancel appointments. We
request 24 hours’ notice for rescheduled or cancelled appointments.
If you are late for an appointment, we may need to reschedule it.
If you don’t show up for your appointment or provide less than 24-hours’
notice, it leaves a period of time when the health care provider could
have seen someone who needs our care. If you have three no-shows, we no
longer will schedule appointments for you.
Please bring your insurance card. If you don’t, you may be responsible
for the office visit charges. If your policy has a copay-ment, please
be prepared to pay it at the time of your visit.
If you don’t have insurance, you must pay for your office visit on
the day of your appointment. If you have questions or need help with insurance,
please call our office before your appointment.
Please allow 1 to 2 business days for refill requests. We cannot dispense
medicines from our clinic without a provider’s approval.
X-rays/MRIs/CT scans/laboratory work
If diagnostic imaging procedures or laboratory tests weren’t performed
at Great River Medical Center, it is your responsibility to bring images
or test results to your appointment. A CD is acceptable.
Workers’ compensation/auto accident
Prior authorization from the insurance company handling your claim is required
for billing workers’ compensation or auto insurance claims. We need
this information: Claim number, date of injury, insurance company, mailing
address for claims, and contact person’s name, telephone number
and fax number.
There is a $10 charge for completing FMLA and disability forms. You will
be notified when the forms are ready, usually within 8 business days.
If your completed form must be faxed, please provide the company name
and fax number. Please note, we do not complete long term disabilty paperwork.
If you cannot comply with this information, please call our office at 319-768-4970,
before your appointment to discuss these requirements.