Bronx Foot Specialist

Oscar Castillo, DPM

Please correct the errors described below.

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I acknowledge that I was provided a copy of the Notice of Privacy practices and that I have (or had the opportunity to read if I so chose) and understood the notice.

DISCLAIMER: 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.

SIGNATURE ON FILE

  • I authorize the doctor named above to use my name on any and all claims documents that relate to health insurance benefits due to me and my dependents.
  • I authorize release of any information related to any claims to all my insurance companies or other relevant parties
  • I understand that I am responsible for my bill and agree to pay all charges for services and items provided to me
  • I authorize my doctor to act as my agent in helping me obtain payment from my insurance companies
  • I authorize payment of health benefits otherwise payable to me, directly to my doctor
  • I permit copy of this authorization to be used in place of the original
  • This “Signature on File” is valid for one year from the date indicated below

DISCLAIMER: 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.

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