Please provide your insurance card(s) for photo copying. (Without current insurance cards you will be considered a Self-Pay account. No Exceptions.)
PLEASE READ CAREFULLY
I give permission to PMFAC to administer treatment and to perform such minor operative procedures as may be deemed necessary in the diagnosis and/or treatment of my condition. I request that my insurance company pay benefits directly to PMFAC. I agree that I am responsible for any amount not covered by my insurance. I agree that it is my responsibility to obtain any referral necessary from my insurance company or Primary Care Physician as required to process my insurance claims. I give permission to use my cell number as a contact number regarding my account.
In the event that I need hospitalization, surgery and/or durable medical equipment, I agree that it is my responsibility to inform the Doctor of my insurance company requirements regarding precertification, second opinions and other requirements.
I understand that monthly finance charges will be added to overdue accounts. I understand that even though Purvis-Moyer Foot & Ankle Center files with my insurance company, if for some reason they do not pay, I accept full responsibility for payment.
AUTHORIZATION TO RELEASE/RECEIVE MEDICAL INFORMATION
I authorize Purvis-Moyer Foot & Ankle Center to release and/or receive medical information to or from my insurance company or any facility that requires information to provide payment or outside care.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read (or had the opportunity to read if I so chose) and understood the Notice.
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.