Rhinebeck Podiatry Services
Patients who are a member of a plan with which we participate are responsible at the time of service for all co-pays, deductibles and non-covered services and materials. Patients who are members of a plan which this office does not participate are fully responsible for all procedures and materials at the time of service. Medicare patients are responsible for non-covered materials, charges applied to their deductible and 20% of the office fees once the deductible has been satisfied. Secondary insurances will be billed if provided.
I have read the above and fully understand my financial responsibilities for all services and materials received in this office.
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.
I understand that I am financially responsible for any balance not covered by my insurance.
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.
I acknowledge that this office distributes miscellaneous medical "over-the-counter" type supplies and physician dispensed medications that are not covered by insurances but are available for purchase on a cash pay basis. I further acknowledge that this office will not bill the private insurance companies for these purchased items.
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.
I authorize Rhinebeck Podiatry Services to RELEASE my protected health information (PHI) to:
I authorize Rhinebeck Podiatry Services to RECEIVE my protected health information (PHI) from:
With this knowledge, I give my authorization to the release of all information in my medical records, including any information concerning my identity, and release RHINEBECK PODIATRY SERVICES, affiliates, agents and employees from any liability in connection with the release of the information contained therein.
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.
I hereby authorize Rhinebeck Podiatry Services for any provider having treated me or my dependent, to release to government agencies, insurance carriers, or others who are financially liable for such professional and medical care, all information needed to substantiate claim and payment.
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.
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