We would like to take this opportunity to welcome you to our practice and thank you for choosing our office to provide you with quality podiatric care. Please carefully read and sign the following below.

You are responsible for any copays and deductible at the time of service, if you don’t pay that day, a billing fee of $15 will be charged to you.

Checks returned for non-payment (bounced checks) will incur a $30 charge.

Every “no show” delays the opportunity for evaluation of other individuals. We ask you help us by giving 24 hours advanced notice of cancellation or rescheduling.

I understand that an appointment time has been made for me and if I do not keep my scheduled appointment, or if I do not give 24 hour advance notice, I will be charged a $45.00 no show fee. I also understand that if the fee is not paid it will be sent through the normal collection process.

If it becomes necessary for the account to be referred to an attorney for collection or suit, the undersigned shall pay reasonable attorney’s fees and collection expenses. Further, I understand that coinsurance, unsatisfied deductible amounts, etc. are requested at time of service unless other financial arrangements have been made in advance.

Multiple cancellations and non-payment of no show fee will result in you being referred to a different medical practice.

I understand that New Patient Forms 1-4 must be fully completed, signed and returned to Hollowbrook Foot Specialist, PC before my appointment.

If your insurance requires a referral you are responsible for getting before you are seen in our office. If you are seen and you did not get a referral you will be responsible for the charges incurred.

I hereby assign payment directly to Hollowbrook Foot Specialist PC, the insurance benefits otherwise payable to me. I understand that I am financially responsible for the charges not covered by this authorization. I also authorize a photocopy of this as if it were an original copy.

I understand the above policies and agree to the terms.

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA I nderstand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

• Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment);
• Obtaining payment from third party payers (e.g. my insurance company);
• The day-to-day healthcare operations of your practice.

I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.