Please present primary and secondary insurance card(s) so we may make a copy, along with your driver’s license or valid photo identification. If you do not have your card, you will be responsible for services rendered at that time, due to the overwhelming number of addresses for each insurance company and the necessity of having your ID#. As well, if a referral is needed, you need to supply it at time of visit. Please take note this office will only submit to two insurances. If this is workers compensation, auto claim, or claims going to your lawyer, please supply that information on date of service. But please take note, you will ultimately be responsible for the bill.
Please be aware it is your responsibility to be aware if your insurance does not cover benefits for podiatry services or a particular service or treatment (diagnosis/billing code), under your plan. We strongly suggest that you call your insurance so that you understand your benefits and coverage, and the insurance’s disclaimer that they DO NOT GUARANTEE PAYMENT, not even with an authorization.
Some insurances are just administrators and actual coverage or if we are in network may be different. So please call your insurance on the back of the card under member services to verify if we are on your plan and what your benefits/coverage includes for services, treatments, and durable medical equipment if necessary. When you call insurance, please make note with whom you spoke and reference #, as we do, in case needed for appeals. But please be aware we will do all that is required for appeal on our behalf, but you may have to call and send written documentation to your insurance as well. If appeal is unsuccessful, you are ultimately responsible for any services or products.
Please follow up with your insurance on any Coordination of Benefits (COB) so your claim is not denied in which you will receive a bill.
I HEREBY AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS MY CLAIM(S) AND HEREBY ASSIGN FOOT HEALTH CENTER, LLC (DR. MICHAEL VERDI, DR. KIRSTEN DISCEPOLA, Dr. MERIHAN BOTROS, AND DR. DOUGLAS N. DELORENZO.) ALL PAYMENTS FOR MEDICAL SERVICES RENDERED TO SELF OR DEPENDENTS.
I ACKNOWLEDGE THAT I AM RESPONSIBLE FOR ALL OF THE CHARGES FOR ALL OF THE SERVICES AND/OR PRODUCTS RENDERED TO ME OR ANY MEMBER OF MY FAMILY.
ALTHOUGH I HAVE REQUESTED THE DOCTOR TO BILL MY INSURANCE ON MY BEHALF, I CLEARLY UNDERSTAND THAT IF A BILL IS NOT PAID BY MY INSURANCE WITHIN A TIMELY MANNER, I AGREE TO MAKE ARRANGEMENTS FOR PROMPT PAYMENT TO FOOT HEALTH CENTER, LLC.
I AGREE TO HAVE A VALID REFERRAL (IT IS THE POLICYHOLDER’S RESPONSIBILITY TO KNOW IF INSURANCE REQUIRES REFERRAL) FOR VISIT AND ANYTIME INSURANCE CHANGES. Please supply updated or new insurance cards as you receive them.
PLEASE NOTE: IF YOU HAVE NO INSURANCE YOU WILL BE RESPONSIBLE FOR PAYMENT AT TIME OF SERVICES