I understand that the information provided on this form is true and correct to the best of my knowledge.
I request that payments of authorized benefits be made on my behalf for any services furnished by Arp Foot & Ankle Clinic.
I authorize any holder of information about me to release any information needed to determine these benefits or the benefits payable to related services to the insurance agent.
I recognize my financial obligation of any coinsurance, co-pays or deductibles and non-covered services that may be required. There is a $25.00 no-show fee for missed appointments or appointments cancelled within the 24 hour notice period.
I hereby give permission to Arp Foot & Ankle Clinic and any qualified staff to evaluate, diagnose and treat my foot and/or ankle condition as may be deemed necessary.
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