ABSOLUTE MEDICAL CARE/ ABSOLUTE FOOT AND ANKLE CLINIC
PODIATRIST FIRST VISIT FORM
INSURANCE INFORMATION(Please have all Insurance Cards and Id with you during visit)
SUPPLEMENTAL/ SECONDARY INSURANCE
PATIENT CONSENT FOR TREATMENT
I, Namehereby give my permission to Dr. Rabinovich D.P.M. and his staff and associates to administer treatment and perform such procedures as may be deemed necessary in the diagnosis and/or treatment of my foot-ankle condition(s)
AUTHORIZATION TO RELEASE INFORMATION
I, Namehereby authorize Dr. Rabinovich to release any medical information pertaining to my treatment and permit any insurer to inspect my medical records in connection with charges arising from this treatment in accordance with Health Insurance Portability and Accountability Act of 1996 (HIPAA) and all its provisions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.
I, Name hereby authorize payment of medical benefits to Dr. Rabinovich for services rendered by him in person or under his supervision. I understand that I am financially responsible for any balance not covered by my insurance, including co-pays, deductible, and non-covered services if any. If you do not have insurance, the total agreed upon with the doctor cost of your visit is required at the time of service. If you have a high deductible plan (over $500) with unmet deductible or you are receiving a non-covered service/procedure, a deposit payment will be required at time of service at office cash price fee schedule for procedures/DME received. Missed appointment fee is $40. Should you default on your required payment, collection action is possible.
I have read and accept the financial policy of Absolute Medical Care &Absolute Foot and Ankle Clinic. I authorize payment of medical benefits to the named provider for professional services rendered.
Absolute Foot and Ankle Clinic 3546 N. Milwaukee Ave. Northbrook Il 60062 847-297-9660
Absolute Medical Care 20637 W. Renwick Rd Crest Hill Il 60403 815-838-9505