LoneStar Foot & Ankle Group

We Follow GISD School Closures

New Patients

We Can't Wait to See You!

As a first time patient, we want to make sure you feel welcomed and informed about our first appointment processes.   Because we understand that every patient has unique needs, your first appointment will include us gathering a comprehensive medical history and focused attention on your current medical needs.

Bring Completed Patient Forms to Your First Appointment

We want to spend time getting to know you, conducting a thorough exam, and bringing you immediate relief from pain. In order to serve you to the fullest on your first visit to LoneStar Foot and Ankle Group, we would greatly appreciate you downloading the new patient forms, printing them out, completing them, and bringing them with you to your first appointment. This will help speed up the process and increase our valuable time together creating the personalized treatment plan that will help you move forward towards a pain free, healthy lifestyle.

Prior to your visit, please take the time to fill this paperwork out so that we can expedite your check in process.  Feel free to email completed forms to us at info@lonestarfootandankle.com or fax to 817-573-3368


LFAG Health History Questionnaire



You can activate your account here WWW.YOURHEALTHFILE.COM and start entering information into your chart regarding your reason for visit, Past Medical History, Surgical History and Medications to expedite the check in process.  Please call us if you have any questions! 817-573-3338

Prior to your visit, please take the time to fill this paperwork out so that we can expedite your check in process.  Feel free to email completed forms to us at info@lonestarfootandankle.com or fax to 817-573-3368


LFAG Health History Questionnaire



You can activate your account here WWW.YOURHEALTHFILE.COM and start entering information into your chart regarding your reason for visit, Past Medical History, Surgical History and Medications to expedite the check in process.  Please call us if you have any questions! 817-573-3338

Patient Information

Billing Information

Please bring your driver license and insurance cards to your appointment

Emergency Contact

Person to Contact in Case of Emergency

Practice Information

Race And Ethnicity

Financial Policy

We strongly feel all patients deserve the very best medical care that we can provide. Everyone benefits when financial arrangements are agreed upon. We have prepared this material to acquaint you with our policy. Our professional services are rendered to you, not the insurance company. Payment for treatment is your responsibility.

Financial/insurance Agreements

In the event I have no insurance coverage, I understand that I am responsible for payment of services rendered to me or my dependents at the time of service. I understand if I fail to pay amounts owed: the clinic has the right to secure an outside collection agency and/ or attorney to collect the unpaid debt and to report the unpaid debt to a credit- reporting agency. I further understand that I will be responsible for any additional charges or fees necessitated by securing the collection agency or attorney, including reasonable attorney’s fees. I hereby authorize the release of any information necessary to process insurance claims and request payment of benefits to be made for services rendered to my dependents or to me. I understand I am responsible at the time of service for paying any required co-payment and deductible.


Due to the Health Portability and Accountability Act (HIPAA) of 1996, the following information must be filled out by each patient annually.
Your rights are posted in the waiting rooms at each Lonestar Foot & Ankle Group clinic. Copies of the rights are also available at the receptionist desk if you would like to keep this information for your records.
I authorize Lonestar Foot & Ankle Group to release any of my medical or insurance information necessary to process my medical claims and coordinate/manage my healthcare.

With whom may we discuss information about your care, treatment or diagnosis?

Electronic Medical Records History

Lonestar Foot & Ankle Group utilizes an Electronic Medical Records (EMR) System in our office.

  • We now have the ability to check your prescription eligibility and download your pharmacy history into our system.
  • We also have the added ability to fax mail order prescriptions, review prescription benefits, and drug formulary all while you are in our office.

Medical Records Request Form

All portions of this form must be completed to constitute a valid authorization for release of health information under the Health insurance Portability Accountability Act (HIPAA) privacy regulations. If any field is left blank, the authorization will be considered defective.

I authorize the use and disclosure of health information about me as described below

“Health Information” identifies you (the patient) by name, and includes other demographic information about you. Information may include,but is not limited to medical records, x-ray films, slides, tracings, strips, ect.

I hereby discharge the releasing facility, its agents and employees from any and all liabilities, responsibilities, damages, and claims which might arise from the release of information authorized herein, to include alcohol, drug abuse, communicable disease including HIV status, and/or psychiatric diagnoses compiled during my visit, encounter or hospitalization, or make copies thereof in accordance with the policies of this facility.

If applicable, I agree to the release of my medical or billing records containing the sensitive information listed above.

Protected Health Information used to disclose pursuant to this authorization may be subject to re-disclosure by the recipient and is no longer protected by this privacy rule. If research-related Health Information is used or disclosed for continued research purposes, an expiration date or event does not apply. This authorization will automatically expire 60 days after the date of signature below (except as indicated above), unless an earlier date is specified, or at the conclusion of the specified event. I understand that I have a right to revoke this authorization at anytime; in writing, as stated in the Notice of Privacy Practices, except where the facility has already made disclosures in reliance upon my prior authorization. Treatment, payment, enrollment or eligibility for benefits may not be conditioned on obtaining an authorization if the Health Insurance Portability Accountability Act prohibits such conditioning. If conditioning is permitted, refusal to sign the authorization may result in denial of care or coverage.

Notice To Receiving Agency Or Individual: This information is to be treated in accordance with Health Information
Portability and Accountability Act (HIPAA) privacy regulations.

General Patient Information

Thank you for choosing Lonestar Foot & Ankle Group as your healthcare provider. We are committed to providing you with  quality, affordable healthcare. Because some of our patients have had questions regarding patient and insurance responsibility  for services rendered, we have been advised to develop this. Please review and ask us any questions you may have.  

  1. Insurance. We participate in most insurance plans, including Medicare. If you are not insured by a plan we do business  with, payment in full is expected at each visit. If you are insured by a plan we do business with, but do not have an up-to-date  insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits  is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.  
  2. Co-payments and deductibles. All co-payments and deductibles must be paid at the time of service. This arrangement is  part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients  can be considered fraud. Please help us in upholding the law by paying your co-payment and/or deductible at each visit.  
  3. Non-covered services. Please be aware that some or all of the services you receive may not be covered or not considered  reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of visit and a  signature is required from you prior to services being rendered.  
  4. Proof of insurance. All patients must complete our patient information forms before seeing the doctor. We must obtain a  copy of your driver’s license and current valid insurance to provide proof of insurance. If you fail to provide us with the  correct insurance information in a timely manner, you may be responsible for the balance of a claim.  
  5. Claims submission. We will submit your claims and assist you in any way we reasonably can to help get your claims  paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with  their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company  pays your claim. Your insurance benefit is a contract between you and your insurance company.  
  6. Coverage changes. If your insurance changes, please notify us before your next visit so we can make the appropriate  changes to help you receive your maximum benefits. If your insurance company does not pay your claim in 45 days, the  balance will automatically be billed to you.  
  7. Nonpayment. If your account is over 90 days past due, you will receive a letter stating that you have 20 days to pay your  account in full. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains  unpaid, we may refer your account to a collection agency and you or your immediate family members may be discharged  from this practice. If this is to occur, you will be notified by regular and certified mail that you have 30 days to find  alternative medical care. During that 30-day period, our physician will only be able to treat you on an emergency basis.  
  8. Missed appointments. The staff at Lonestar Foot & Ankle Group understands that certain circumstances require  rescheduling of an appointment. However, three or more “no shows” may result in a patient being discharged from the  provider. A “no show” is defined as when a patient misses an appointment and has not called prior to the appointment time  to reschedule, or is more than 15 minutes late. Our policy is to charge for missed appointments not canceled within a  reasonable amount of time. A charge of  

$25.00 may be billed directly to you. Please help us serve you better by keeping your regularly scheduled appointment.  * Medicare recipients are exempt from the missed appointment charge.  

* If you are a Medicaid recipient your health care plan will be notified of any and all missed appointments  * If 3 or more appointments are missed you may be placed on a work in only list or even discharged from our  practice.  

  1. Date/Time of Appointment. Patients will be called back according to their scheduled appointment time by healthcare  provider. Every effort is made to assure that patients are seen as close to their scheduled appointment time as possible. Patients  whose symptoms are severe, infectious, or change dramatically while waiting may be taken to a patient room as soon as  possible for their appointment. We appreciate your understanding at all times.  

Thank you for understanding our payment policy. Please let us know if you have any questions or concerns.  Please visit our website at: www.lonestarfootandankle.com


Our commitment is to your optimal well-being. In order to make it as easy and convenient as possible for you, we offer a variety of payment methods including:


Insurance can be complicated. We try to make it easy for you. We will be happy to file insurance claims and verify benefits as a courtesy to you. Please bring all necessary insurance information with you on your first visit. We are happy to bill all traditional insurance plans.
Feel free to contact us with any questions pertaining to your insurance benefits at:
(817) 573-FEET (3338).