Statement of Patient Financial Responsibility
Gold Coast Podiatry appreciates the confidence you have shown in choosing us to provide for your foot care needs. The services you have elected to participate in, implies a financial responsibility on your part. The responsibility obligates you to ensure payment in full of our fees. As a courtesy, we will bill your insurance carrier/s on your behalf. However, you are ultimately responsible for payment in full of your bill.
Many insurance companies have additional stipulations that may affect your coverage. It is ultimately the patient’s responsibility to know your coverage and benefits. By signing below, you authorize Gold Coast Podiatry, PC to furnish information to insurance carriers concerning your care. You are responsible for any amounts not covered by your insurance. If your insurance carrier denies any part of your claim, or if you elect to continue services past your coverage/policy period, you will be responsible for your balance in full. It is the patient’s responsibility to obtain referrals or authorizations required by the insurance carrier to be seen at Gold Coast Podiatry, PC. Full payment for Gold Coast Podiatry, PC services provided is due at the time of services rendered; fees and Interest may be charged.
If payment is denied for lack of authorization, by signing below you indicate that you understand that you are responsible for payment in full. You are responsible for payment of any deductible and co-payment/co-insurance as determined by your contract with your insurance carrier. We expect these payments at time of service. Some health insurance carriers require the patient to pay a co-pay for services rendered. This is a contract between you and your insurance carrier. Payment of all co-pays is expected at the time the service is rendered for the patients.
I understand that I am responsible for co-payments and deductible/co-insurance as dictated by my insurance carrier.