Our office makes reminder calls prior to your next visit. Please
initial and date below giving us permission to leave a message or any
medical information as necessary on your answering machine.
release of protected personal patient information
Are there any family members or individuals that you would like our
office to give your personal information?
I/We do hereby consent to and authorize the performance of all
treatments, surgeries and medical services deemed advisable by the
physicians and staff of the Foot and Leg specialty center to me or to
the above-named minor of whom I am the parent or legal guardian. I
hereby certify that, to the best of my knowledge, all statements
contained hereon are true. I understand that I am directly
responsible for all charges incurred for medical services for myself
and my dependents regardless of insurance coverage.
& FINANCIAL INFORMATION:
assignment and release: I certify that I have insurance and assign
direct payments to the fore mentioned company and assign rights to
further appeal any denials of those claims or actions on my behalf.
Further, I authorize the doctor or members of his staff to release
any information needed to determine benefits payable to my insurance
carrier. I understand and agree that health and accident insurance
policies are an arrangement between the carrier and the patient and
accept financial responsibility of services provided if my insurance
company deems the services non-payable or does not process the claims
in a timely manner (typically 60 days). Additionally, I am aware
that I will be responsible for any co-pay and deductible amounts.
understand that I am responsible for charges incurred at the time of
my visit and are due at the time of my visit unless other
arrangements have been arranged. I agree and understand that I may
be charged a 1.5% interest rate per month on any unpaid balance and
that I am responsible for any costs incurred in collection of said
balances should that become necessary.
OR Legal Guardian Signature