Book an Appointment Below with Aloha Foot Centers KAILUA OFFICE ONLY!
STOP! WE DO NOT TAKE WORKER'S COMPENSATION, 3RD PARTY LIABILITY, KAISER OR ANYONE IN HOSPICE CARE! YOU WILL NEED TO PAY OUT OF POCKET FOR THE ENTIRE VISIT ON THE DAY OF YOUR APPOINTMENT. Tricare Prime or Humana. HMSA HMO or Pacific Health Care Group, Humana HMO, Ohana and VA require paper referral.
CALL 808-266-0066 Do not proceed with online booking.
Family History: M=Mother F=Father B=Brother S=Sister
1. Insurance.We participate in most insurance plans, including Medicare. We must obtain a copy of your driver’s license and current valid insurance to provide proof of insurance. If you are not insured by a plan we do business with, payment in full is expected at each visit. If you are insured by a plan we do business with, but don’t have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage. 2. Co-payments and deductibles and deposits.All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Deposits may be due at time of service depending on your insurance and treatment type. 3. Claims submission.We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not a party to that contract 4. Financial hardship. If you are having financial hardships and are unable to pay your co-payments and medical bills consider applying for Medicaid Quest assistance. If you qualify Quest plans have no copays. Return to clinic with your Quest insurance card and we will be able to continue seeing you as a patient and will negotiate and possibly reduce past due debt. 5. Nonpayment.If your account is over 90 days past due, you will receive a letter stating that you have 30 days to pay your account in full. Partial payments with recurrent credit card payments can be negotiated and set up. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you may be discharged from this practice. If this is to occur, you will be notified that you have 30 days to find alternative medical care. During that 30-day period, our physician will only be able to treat you on an emergency basis.
Practice Requirements – HIPAA COMPLIANCE -This Notice is in effect as of 4/15/03. Aloha Foot Centers: a) Is required by federal law to maintain the privacy of your Personal History Information (PHI) and provide you with this privacy notice detailing the practice’s legal duties and privacy practices with respect to your PHI. b) Under the Privacy Rule, may be required by State law to grant greater access or maintain greater restrictions on the use or release of your PHI than that which is provided for under federal law. c) Is required to abide by the terms of this privacy notice. d) Reserves the right to change the terms of this privacy notice and to make the new privacy notice provisions effective for all of your PHI that it maintains. e) Will distribute any revised privacy notice to you prior to implementation. f) Will not retaliate against you for filing a complaint. I acknowledge I have read this notice, understand the information and agree to its terms. I can have a copy of this notice at any time. I certify that the above information is complete and correct to the best of my knowledge. I give permission to Aloha Foot Centers to file all medical claims on my behalf. I request that payment of authorized benefits be made to Aloha Foot Centers on my behalf for medical services rendered to me. I consent to have my photo taken for my medical records.
I have read and understand the HIPAA and Payment Policy and agree to abide by its guidelines.
Signature of patient / Signature of legal guardian responsible for bill Relationship to patient Date Page 2 of 2