Any contact information listed on this form, including phone numbers and email, will be used by this office to contact you about future appointments, billing, and routine correspondence.
I give my consent for (i.e. spouse, partner, adult child, etc.) to discuss and/or obtain my NOPA-related account information in person, by phone, or by email. I understand I may revoke given consent in writing at any time.
You have the right and choice to tell New Orleans Podiatry Associates hereafter referred to as “NOPA” to share information with your family, close friends, or others involved in payment for your case and/or to share information in a disaster relief situation.
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our website, and we will mail a copy to you.
I hereby give my consent for the physicians and team of New Orleans Podiatry Associates to use and disclose protected health information about me to carry out treatment, bill insurance carriers, and to conduct normal healthcare operations.
I acknowledge by my signature that I have read both pages of this Consent for Purposes of Treatment, Payment, Healthcare Operations, and HIPAA, and I have been given a copy for my personal use.
New Orleans Podiatry Associates and its representatives are not authorized to quote medical benefits to you; however, we will share with you the information your insurance carrier has provided us. Many of our patients rely on this data to make treatment decisions, however, this information is sometimes inaccurate. Therefore, it is your responsibility to contact your insurance carrier before receiving treatment to ensure we are a provider for your insurance plan, and/or to learn how your visits with our doctors will be reimbursed.
Upon request, this office will provide you with the diagnosis codes and procedure codes related to your treatment. These codes are needed by your carrier to obtain coverage information.
According to industry standards, New Orleans Podiatry Associates will file your medical claims for all applicable medical services and appliances rendered to you by our physicians, unless an ABN or similar waiver is signed.
Co-payments, co-insurances, non-covered services and deductible responsibilities are due at time of service.
In order to bill your insurance carrier, New Orleans Podiatry Associates shall maintain a copy of your insurance card(s) as per our contract with your insurance carrier. At least 24 hours prior to your visit it is your responsibility to ensure our office has your most current insurance information or your appointment may be rescheduled.
In order to bill your insurance carrier, New Orleans Podiatry Associates shall maintain a copy of your driver's license or State ID as per our contract with your insurance carrier. At the time of your initial visit, it is your responsibility to ensure you bring with you the above identification or your appointment may be rescheduled.
In order to bill your insurance carrier, if you are an established patient and you have made a change to your insurance coverage and you do not have your new insurance card or a copy of the card with you at the time of your visit, you will either be rescheduled or you may choose to pay out of pocket for your visit and services when rendered.
In all cases, if your insurance carrier places expenses to your financial responsibility, then you, the patient, are responsible for those charges, due on the date of service or upon receipt of invoice. Non-collectible debt will be shared with a recovery agency.
The accounts of minor children are the responsibilities of their parents or legal guardians. In the event there is a non-collectible debt associated with the account for a minor child, the parent or legal guardian will be held responsible and their information will be shared with a recovery agency.
Our banking institution charges for returned checks; therefore, and without exception, a $50.00 service charge will be billed to you in the event your check is returned for any reason.
If you choose to use a debit or credit card to pay for services, a 3% service charge will be added to your total and placed to your responsibility. This fee is one-half of what we are charged to process your card; we are splitting the difference with you.
If you are a caregiver and you accompany a cognitively compromised individual to our office for medical care, a medical power of attorney is necessary before the individual will be accepted into our practice as a patient.
We will file all charges with Medicare and your supplemental insurance if applicable. If you do not have supplemental insurance, you are responsible for the 20% not paid by Medicare, or any deductible that has not been met at the time of service.
Regarding workmen’s compensation/auto/liability, our office requires a very specific authorization prior to the initial visit. If the authorization has not been received by the time of your visit, then your personal health insurance information will be taken for filing purposes or you may pay out of pocket at the time services are rendered. You will be responsible for all fees until the case has been settled. We do not bill attorneys in workmen’s compensation, auto and/or liability cases.
Patients under the age of 18 must have a parent and/or guardian accompany them to our office before treatment can be rendered. Arrangements must be made prior to being seen with the parent and/or guardian for any copays and payments to be made at the time of treatment.
Our office uses both an out of state laboratory as well as an in-house, physician owned laboratory for PCR services, bacterial cultures and fungal cultures. In the event that a lab test is performed, you will receive a separate bill for the lab services.
If your insurance does not cover orthotics or your deductible has not been met, a deposit of half the price of the orthotics will be expected prior to ordering. The remaining half is due at the time your orthotics are dispensed.
I understand that if I fail to satisfy my financial responsibility with New Orleans Podiatry Associates, I imply discontinuation of podiatry services with this clinic.
I have read, understand, and agree to the above. By signing below, I attest that my questions have been answered and I agree to comply with the patient responsibilities policies.
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