East Bay Foot Clinic, Inc.
I understand and acknowledge that this general consent and acknowledgement applies to care and treatment and his associates, who may be involved in my care to provide such diagnoses and treatment considered necessary such as wound care, diagnostic testing, home health, and durable medical equipment (DME) products for the care I am seeking as may otherwise be advisable.
I, undersigned certify that I (or my dependent) have insurance with:
and assign directly to Dr. Zeineldin Ahmad, D.P.M. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all the charges whether or not paid by insurance. I, hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions. I understand that if my Podiatry services are not covered, I will be responsible for the payment of $75.00 on services rendered.
I request that payment of authorized Medicare Benefits be made either to me or on my behalf to Dr. Zeineldin Ahmad, D.P.M. for any services furnished to me by that physician. I authorize any holder of medical information about me to release the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If other health insurance is indicated in item 9 of the HCFA 1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signatures authorize releasing the information to the insurer or agency shown. In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carriers the full charge, and the patient is responsible only for the deductible based upon the charge determination of the Medicare carrier.
I understand that I have the right and responsibility to participate in my care and treatment. I understand that I have the right to be informed about the treatment being recommended, and the responsibility to ask questions if I do not understand it. I agree to provide accurate and complete information about my health history and presenting complaints, to agree upon a treatment plan, and follow that plan. I agree to participate and cooperate in my own care and treatment. I understand that my Healthcare providers will treat me with respect. and I agree to do the same.
I understand that Dr. Zeineldin Ahmad, D.P.M. and his associates will use and disclose my health information for the purpose of treatment, payment, and Healthcare operations. I understand, acknowledge, and consent to release of my personal health information for the purpose outlined in this section as described in the Notice of Privacy Practice pamphlet which has been offered to me, and as may otherwise be permitted by law.
The following is a list of insurance companies that East Bay Foot Clinic, Inc. is contracted with. If you don't see your specific plan or product below, please contact our office at 925.474.4519 or 925.474.4513 prior to a scheduled visit to check if you're covered or that East Bay Foot Clinic, Inc. is a participating provider with your insurance plan. Please note all the John Muir HMO plans require a referral from a referring physician. The referral will need to be obtained prior to treatment.
For all other insurance plans not mentioned above, ie. Medicare with Kaiser, Western Health Advantage, Humana, etc. will be considered an out of pocket cost. The cost for the services for non covered patients or patients with an "out of network" plan is $75.00. Example: Patient has Medicare with Kaiser insurance, we are unable to submit claims since we are not contracted with Kaiser. This will result in a $75.00 charge in which the patient is responsible.
Please bring your insurance card with you at your initial visit. It is the patient's responsibility to notify staff of any insurance changes.
We will file claims with the patient's insurance upon the patient's submission of proof of insurance (i,e., insurance card indicating coverage, ID number and group number).In the event the patient has insurance coverage but cannot provide documentation, payment is due at the time of service. Upon receipt of the insurance card, we will submit the health insurance claim indicating patient payment at the time of service.
Claims will be filed with secondary insurance if adequate information is received at the time of service.
If no insurance is to be filed by us, or if we are not a participating provider in your insurance plan, Full payment is expected. If necessary, we can set up a payment schedule. Payment arrangements will be made with a signed payment agreement and the approval of the office manager. Deductibles, and co-payments will be billed to the patient directly. Payments for non-covered services are due at the time of service or will be billed to the patient directly.
Please sign and date confirming that you understand and acknowledge all of the above.
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