Patient Demographics and HIPAA

Tola Foot & Ankle Center - Pamela Tola, DPM - Podiatric Medicine & Wellness located in Hamilton, NJ

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If the patient is insured under parents plan, please complete the following:

  1. CONSENT FOR TREATMENT: I give Tola Foot & Ankle Center permission to examine and treat, perform tests and procedures that are necessary in the diagnosis and/or treatment of my foot/ankle/leg disorders.
  2. FINANCIAL POLICY: I certify that I (or my dependent) have coverage with my insurance and am responsible for informing the office if there is any change in my health insurance information. For my visits in this office, I assign all insurance payments to be payable to Dr. Pamela F. Tola. I understand that I am responsible for payment of deductibles, co-payments, and/or non-covered services. I allow the release of medical information to my health insurance for payment, or requested physician for the purpose of treatment and/or to provide continuity of care. I authorize the use of this signature on all health insurance claim form submissions
  3. PRIVACY NOTICE: I certify that I have read (or had the opportunity to read if I so chose) and understand the HIPAA Notice of Privacy Practices. Our office’s full HIPAA policy is available upon my request.

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