If the patient is a minor, please complete this section
All Patients, Please Read & Sign
I authorize payment of medical benefits from Medicare, Medigap, private and/or group insurance be made on my behalf to Idaho
Foot & Ankle for any services or supplied furnished to me. I authorize any holder of medical information about me to release to the
Health Care Financing Administration or my insurance company any information needed to determine benefits for related services.
I also take responsibility for payment of charges, regardless of payment or denial of payment from my insurance company.
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