If you do not have insurance, please be prepared to fully cover the fees for each visit at time of treatment.
If you have secondary insurance, we will bill them one time. If your secondary insurance does not pay the balance within 45 days, that balance will be billed to you and due at that time.
The adult or parent (custodial guardian) accompanying a minor is responsible for payment of services. Young adult (age 18 or over) are legally responsible for their accounts unless a parent accompanies them to the initial appointment and signs this financial agreement, regardless of insurance coverage.
To provide the best possible treatment plan for you, our doctor offers every level of podiatric care. Often, the use of a foot care product is an appropriate treatment for a successful outcome. For your convenience, we make some supplies available for purchase through R&M Medical and Supply . R&M Medical and Supply is located here in our office but is not contracted with any insurance companies, so payment is due at time of sale. Our doctor is happy to offer a prescription for a comparable product if you would prefer to obtain the supplies through your pharmacy.
I have read and agree to the terms set forth in the above financial policy. I also understand that I am financially responsible for any treatment rendered to me or minor child by Foot & Ankle Center of Lake City. I, therefore, authorize Foot & Ankle Center of Lake City to release and or exchange medical records, billing and collection information for the purpose of obtaining payment for services rendered.
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.