If any of the first three boxes are checked, the patient should not enter this building and should call their primary care doctor immediately.
Policy Holder's Name (If other than self)
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
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I hereby give permission to Dr. Jill Hagen, DPM / Dr. Lauren Grossman, DPM and/or associates for the examination and rendering care for my foot problem and/or related condition.
If other than the above, please discuss payment with the office receptionist.
Thank you for choosing us as your health care provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our FINANCIAL POLICY which we require you to read and sign prior to initial treatment.
Your insurance policy is a contract between you and your insurance company. We are not a part of that contract. Please be aware that some of the services provided may be non-covered services and not considered reasonable and necessary under the Medicare program and other medical insurance programs. Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rates. You are responsible for all non-covered services, deductibles, copays, and coinsurance.
ADULT PATIENTS AND MINOR PATIENTS: Adult patients (18 or older) are responsible for payment.
The adult accompanying the minor and the parents (or guardian of the minor) are responsible for payment. For unaccompanied minors, non-emergency treatment will be denied unless payment by Cash, Check, MASTERCARD, VISA, Venmo, or Zelle at the time of service has been verified.
PATIENT LIABILITY: If this account is assigned to an attorney for collection and/or suit, I shall pay 33 1/3% of the claim as payment for attorney's fees and cost of collection.
CHECK RETURN POLICY: For any check that is returned from the bank, there will be a service charge of $30.00 that must be paid to Podiatry Associates.
Thank you for understanding our Financial Policy. Please let us know if you have any questions or concerns.
I HAVE READ THE FINANCIAL POLICY. I UNDERSTAND AND AGREE TO THIS FINANCIAL POLICY.
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The health insurance affordability and accountability act (HIPPA) provides safeguards to protect your privacy. Implementation of HIPPA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a “friendly” version. A more complete text is posted in the office.
What this all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPPA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the US Department of Health and Human Services. www.hhs.gov
We have adopted the following policies:
do hereby consent and acknowledge my agreement to the terms set forth in the HIPPA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.
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