PARTICIPATING INSURANCE FORM

Participating insurance:

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.

Non participating insurance plans:

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 can be discussed with the office staff, as all services vary in pricing.

Insurance claims:

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Primary Insurance:

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.

Secondary Insurance:

Claims will be filed with secondary insurance if adequate information is received at the time of service.

Patient Financial Responsibility:

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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