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Patient Information

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RESPONSIBLE PARTY OR NAME UNDER INSURANCE

MEDICAL INFORMATION

Information Release Authorization

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REFERRAL INFORMATION

Balances Due and Credit or Debit Card on File Policy

It is the policy of Kansas City Foot and Ankle to have a credit or debit card on file for all patients. The credit or debit card on file will be used for co-pays, in-office purchases or balances due on your account.

(Medicare subscribers with a secondary plan are not required to keep a credit card on file)

Your insurance plan is required to send you an Explanation of Benefits (EOB), which will state any balance remaining to be paid by you. If your insurance carrier assigns any additional patient responsibility amounts after the claim is processed, we will contact you by automated phone call, email or text message to alert you of the balance due on your account 7 days before processing the payment with your card on file.*

*Balances of $25 or less may be charged automatically without notification.

Should you decide to use an alternate method of payment, please alert our office within the 7-day notice period.

If your credit or debit card on file expires or otherwise becomes noncollectable, we will contact you to promptly provide a new credit or debit card for payment on account balances.

If after insurance has processed and your account acquires a credit and no outstanding services are pending, a refund will be made back to the card originally used.

A receipt may be emailed or mailed to you to confirm your payment upon request. Receipts and statements are available on the patient portal.

Account balances remaining unpaid for more than 45 days will become eligible for collections process.

Please sign below to acknowledge understanding of the above financial policy.

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.

Financial Policy and Patient Authorization for Kansas City Foot and Ankle, PC

Thank you for choosing our office for your medical care. We are committed to providing you with high quality health care. The medical services provided by our office are services you have elected to receive which may imply a financial responsibility on your part.

INSURANCE: We participate in most insurance plans including Medicare. If you are not insured by a plan we participate with, payment in full is expected at each visit. If you are insured by a plan we participate with, but do not have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage. If you are seeing our doctors on an “out of network” basis, you will be subject to out of network rates. We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company. You are responsible for all authorizations/referrals/pre-certifications needed to seek treatment with Kansas City Foot and Ankle physicians. Your medical claim will be forwarded to your secondary insurance (if any) after payment and/or explanation of benefits (EOB) is received from your primary insurance company.

COPAYMENTS AND DEDUCTIBLES: All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company and we are required by law to collect co-payments and deductible payments at the time of service. Please assist us in compliance with our obligations by paying your co-payment and deductible payment at each visit. In the event that you do not pay your copayment or deductible payment at the time of service, we will charge the credit card on file for such co-payment or deductible amount.

SELF PAY: Payment in full is due at the time of service if you do not have health insurance.

NON-COVERED SERVICES: Please be aware that some of the services you receive may not be covered or not considered reasonable or necessary by Medicare or other insurers. You are responsible for payment of these services.

CANCELLATIONS: Your appointment time has been reserved specifically for you. In the event that you will be unable to attend your scheduled appointment, we ask that you call our office at least 24 hours in advance in order to cancel or reschedule your appointment. This will allow us to offer this appointment time to another patient who may need our services. If our office does not receive 24 hours’ notice of your cancellation, you may be charged a $50 “no-show fee.” These charges are not covered by your insurance and are due before any other appointments will be rescheduled. Our office staff or voicemail will note the date and time of your call. In the event that you must cancel and cannot reach the office personnel, please leave a message with our answering service or on our voicemail system. No fee will be charged if your call is received within the above time frame.

PRIVACY STATEMENT: Any information disclosed in your records will remain confidential and will not be used for any other reason except in providing quality care and treatment as well as to submit your claim to your insurance company and contact you as needed.

PATIENT BILLING: You will receive a receipt of all charges. By executing this Financial Policy and Patient Authorization, you hereby guarantee payment of all charges from Kansas City Foot & Ankle, P.C. for medical services and treatment provided. If for any reason we are unable to collect payment in full via credit/debit card on file on file you will receive notice requiring immediate payment for services. If we do not receive payment in full for the balance due, a second and last notice will be provided. If after the second and last notice we do not receive payment in full for the balance due, your account may be forwarded to collections, and you hereby agree that if Kansas City Foot & Ankle, P.C. places your account with an agency or attorney for collection, you will pay Kansas City Foot & Ankle, P.C. all of its costs and expenses in collecting monies owed by you to the extent allowed by applicable law. We accept the following payment methods: Cash, Check, credit/debit, or Care Credit. An additional fee up to $25.00 will be added to your statement if the payment is returned for insufficient funds. In the event that your insurance company should happen to send payment to you, the patient, we expect that you would forward it to our office to be applied to your balance.

ASSIGNMENT OF BENEFITS: I, the undersigned, certify that I (or my dependent) have coverage with my insurance as presented and assign directly to Kansas City Foot and Ankle, PC all insurance benefits, payable to me for services rendered. I understand that I am responsible for payment of deductibles, co-payments, and/or noncovered services. I hereby authorize the doctor to release all information necessary to secure payment of benefits. I authorize RELEASE OF MEDICAL INFORMATION to my insurance carrier, or requested physician to provide continuity of care. I authorize the use of this signature on all insurance submissions.

I acknowledge and understand that it is my responsibility to inform the doctor’s office if there is a change in my health insurance information and acknowledge I was provided with a copy of the Notice of Privacy Practices and understand and accept its terms.

AUTHORIZATIONS: I hereby acknowledge that I have read the above policy regarding my financial responsibility to Kansas City Foot and Ankle, P.C. for medical services and treatment provided and I agree to pay Kansas City Foot and Ankle, P.C. any balance unpaid by my insurance carrier for myself or the below named person.

I hereby authorize Kansas City Foot & Ankle, P.C. to charge my credit card or debit card on file the full amount owed by me for all services and/or treatment rendered by Kansas City Foot & Ankle, P.C. in accordance with the terms above. In the event I provide a cash deposit to Kansas City Foot & Ankle, P.C. in lieu of having a credit or debit card on file, I hereby authorize Kansas City Foot & Ankle, P.C. to deduct from such cash deposit the full amount owed by me for all services and/or treatment rendered by Kansas City Foot & Ankle, P.C.

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.

FINANCIALLY RESPONSIBLE PARTY(if other than patient)

Privacy Practices

I hereby give my consent for Dr. Mark Green, Dr. Stephanie Jameson, Dr. Corey Bess, and Dr. Ethan Knowlton dba Kansas City Foot & Ankle, PC to use and disclose protected health information (PHI) about me to carry out treatment, payment, and healthcare operations (TPO). (Kansas City Foot and Ankle, PC’s Notice of Privacy Practices provides a more complete description of such uses and disclosures.)

I have the right to review the Notice of Privacy Practices prior to signing this consent. Kansas City Foot & Ankle, PC reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Kansas City Foot & Ankle, PC, Privacy Officer, at 1010 Carondelet Drive #301, Kansas City, MO 64114.

With this consent, Kansas City Foot & Ankle, PC may call m y home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items, and any calls pertaining to my clinical care, including laboratory results among others. However, our policy is not to leave detailed messages regarding Protected Health Information or anything related to treatment or healthcare operations.

With this consent, Kansas City Foot & Ankle, PC may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked “Personal and Confidential.”

With this consent, Kansas City Foot & Ankle, PC may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Kansas City Foot & Ankle, PC restrict how it uses or discloses my PHI to carry out TPO.

However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to Kansas City Foot & Ankle, PC’s use and disclosure of my PHI to carry out TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Kansas City Foot & Ankle, PC may decline to provide treatment.

I understand these policies and accept responsibility for payment of my account.

Authorization to Release Medical Benefits

I authorize the release of all medical information necessary to process insurance claim(s) and I hereby assign and authorize direct payment of all medical and/or surgical benefits, including major medical, private insurance, and other health plans to Kansas City Foot & Ankle, PC.

Please remember that medical insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some insurance companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, coinsurance, or any other balance not paid by your insurance.

If this account is assigned to an attorney for collection and/or suit, the prevailing party shall be entitled to reasonable attorney’s fees and costs of collection.

To the extent necessary to determine liability of payment and to obtain reimbursement, I authorize disclosure of portions of my (the patient’s) medical record.

This assignment will remain in effect until revoked by me in writing. A signed photocopy of this assignment will be considered as valid as an original.

Disclosure of Ownership Interest

Stephanie Jameson holds ownership interest in the HCA Surgery Center of Johnson County, Coliseum Imaging Center and Modern Vascular of Overland Park.

Mark Green holds ownership interest in the HCA Surgery Center of Johnson County.

Medicare Lifetime Signature on File

If applicable, I request that payment of authorized Medicare benefits be made on my behalf to Kansas City Foot & Ankle, PC for any services furnished me by its physician(s). I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for related services.

Lifetime Consent

If applicable, I request that payment of authorized Medigap or other secondary or tertiary benefits be made on my behalf to Kansas City Foot & Ankle, PC for any services furnished me by its physician(s). I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for related services.

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.

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