Update Patient Packet

Please correct the errors described below.

Patient Information

I certify that I have insurance with the above named insurance Company and assign directly to Hampton Roads Foot and Ankle Specialists all insurance benefits related to my visit. I also authorize HRFAS to use my health care information with the above insurance companies and their agents for the purpose of obtaining payment for services, determining insurance benefits or the benefits payable for the related services. I agree that I am responsible for any unpaid balance including deductibles, copayments, noncovered services, and any portion of covered services not paid in full by the plan and understand that such payments are due at the time of service or immediately upon presentation of the bill. If any account remains unpaid for 90 days and is referred for collection, the responsible party agrees to pay the costs of collection and attorney’s fees of 33.3% added to the account balance.

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.

Patient Responsibility and Financial Agreement

As a Patient of Hampton Roads Foot and Ankle Specialists, I agree to the following:

1. Medical Treatment Risks: I acknowledge that all medical treatments involve some risks and that no guarantee can be given regarding the outcome.

2. Release of Prescription History: I authorize any physician who is treating me on behalf of HRFAS to request and receive any and all information regarding my medication history, including information maintained by the Virginia Prescription Monitoring Program.

3. Narcotics: I understand that this is not a pain management clinic and any prescriptions for pain medication will be written for no more than seven (7) days and for no more than fourteen (14) days total.

4. HIV Testing Disclosure: Under Virginia law, if a HRFAS employee comes in contact with your blood or bodily fluids during your care, HRFAS has the right to do a current HIV and Hepatitis B or C screening. This means that you, the patient may be tested for HIV Hepatitis B, or C viruses without your actual consent, if this type of exposure occurs during your medical care. The law also requires that the results of these tests be released to the person who was exposed to your blood or bodily fluids, without your consent.

5. Financial Responsibility: I assign any benefits to HRFAS that I may have for reimbursement for my medical treatment received by HRFAS, which I may be entitled to from any insurance coverage, workers compensation benefits, disability benefits, and all settlements, judgements and verdicts against any liable third party. If I fail to pay my outstanding balance, I understand HRFAS is due such settlement, judgement, or verdict equal to the full amount of any unpaid bill. I further direct any attorney handling or disbursing such proceeds to withhold and promptly pay HRFAS the full amount of any outstanding balance owed by me, the patient, to HRFAS for medical services rendered.

6. All payments Due at Time of Service: HRFAS, as a courtesy to our patients, will bill most insurance companies. I understand I am responsible for all co-pays, deductible, cost-shares and non-covered services. By signing this agreement, I accept full responsibility of all HRFAS charges. Full payment is required at time of service unless other arrangements have been made. If any HRFAS bill is not paid in full within 60 days of service, HRFAS reserves the right to charge interest at a monthly rate of 1.5% and a minimum charge of $2.50 month from the time of delinquency on any outstanding balance. If any account balance remains unpaid for 90 days and HRFAS refers the account to a collection agency or attorney for collection, the responsible parties agree to pay the costs of collection and that such fees and costs will be added to the account balance. In a legal action between the parties this agreement will be used to collect and unpaid balances due for medical services rendered, HRFAS shall be entitled to recover attorney’s fees of 33.3% and any and all court costs and fees associated with collecting payment. I also understand and agree to pay a $40.00 fee incurred for any returned checks.

7. Preauthorization Responsibility: I understand it is my sole responsibility to obtain all required preauthorizations for treatment and to fully comply with all pre-authorization requirements as stated by my insurance company.

8. Disclosure of Medical Information and Assignment of benefits: I authorize HRFAS to share my medical information and medical records to my insurance company, physicians and third party payers. I also assign benefits payable for physicians’ services to the physicians or organization furnishing the services or authorize such physicians or organization to submit a claim to Medicare for payment.

9. No Show policy: If for any reason you are unable to keep your appointment, please call our office to reschedule or cancel at least 24 hours in advance, so that someone else may benefit from the appointment slot. I understand failure to call at least 24 hours in advance will result in a $40.00 no show fee, which is NOT billable to insurance. I understand that after 2 missed appointments without calling to cancel HRFAS will not offer and any additional appointments and my care must be transferred to another practice.

10. Surgery Cancellation: A minimum of 7 days notification is required for surgery cancellation. This allows the physician and staff time to fill the slot with another patient. If you must cancel your procedure, please call our office and ask to speak to the surgical coordinator. I have read this policy and understand that cancellation of my procedure for reasons other than medical, may result in a $100.00 fee not payable by insurance.


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.

Notice of Privacy Practices:

I am aware of and/ or received Hampton Roads Foot and Ankle Specialists Notice of Privacy Practices. Upon receiving an inquiry as to the presence or condition of the Patient, HRFAS may (unless otherwise requested by the patient, next of kin, or physician) release at its discretion: the name, address, age, sex, general nature of injuries, and/ or the general condition of the Patient. I understand that a separate written consent is required for me and or the person(s) listed below to receive copies of my written medical records. . I authorize release and exchange of my medical information between medical offices for the purpose of billing and coordinating my medical care.

However, I hereby give my permission to my physician & office personnel to verbally discuss any and all of my medical conditions with the following persons.

Add Name

Hampton Roads Foot & Ankle Specialists

1155 Professional Drive

Williamsburg, VA 23185


2114 Hartford Dr, Ste A

Hampton, VA 23666


Enclosed you will find our update of your information packet, please complete it in its entirety. Patients must arrive 15 minutes PRIOR to your appointment time. Please remember to bring your insurance card(s), and picture ID.

If you have a deductible and/or co-insurances, payment in full is due at the time of your appointment unless other arrangements have been made prior to. Our office will make every effort to inform you of your financial responsibility prior to performing any services. Please contact your insurance company if you are unsure of your insurance benefits.

*Williamsburg-This office is located off of 199 in the Governor Berkeley Professional Center off of John Tyler Lane. Our office is in the cul-de-sac on the left 1155. Our logo is on the front of the building.

*Hampton -This office is located on Hartford Rd across the street from Bayport credit Union between the Hampton Coliseum mall and Marcella.

Thank you for entrusting our office with your health care needs. We look forward to providing you with the best care possible.

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