EMPLOYER
SPOUSE / GUARANTOR
INSURANCE INFORMATION
Primary Carrier:
Other Carrier
ALL CHARGES INCURRED ARE DUE AND PAYABLE AT THE TIME OF THE VISIT UNLESS PRIOR ARRANGEMENTS HAVE BEEN MADE.
I hereby give my permission for the doctor to render the proposed Podiatric examination and treatment. I understand that I am financially responsible to the Physician for all charges incurred by me or my dependents. I authorize the release of any medical information necessary to process any claim and request payment of insurance benefits due to be paid to the Physician supplying the service. I authorize the use of this form on all of my insurance submissions. I authorize my doctor to act as my agent in helping me obtain payment from my insurance Companies. I permit a copy of this authorization to be used in place of the original.
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.
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.
Your information will be encrypted.