PLEASE READ AND SIGNThe above information is correct to the best of my knowledge. I understand that throughout my treatment, I am responsible for notifying the physician and/or medical staff of any and all updates to the information listed above.
Review of Systems (Please check the box if you currently have any of these symptoms or check “NONE”)
Privacy Information Preferences
PLEASE READ AND SIGN: The information on my intake form(s) is correct to the best of my knowledge. I understand that throughout my treatment, I am responsible for notifying the physician and/or medical staff of any and all updates to the information listed above. (Assignment of Benefits): I authorize payment of medical benefits to the practice named above. (Release of Information): I authorize the release of any medical information necessary to process this claim. (HIPAA Privacy): I acknowledge that I received my HIPAA Privacy Practices Notice. (Medication History): I authorize the Doctor’s office to retrieve my medication history.
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.
I fully understand that I am ultimately responsible for any and all charges associated with my account and that if I fail to pay any amount due, I will also be responsible for all collection fees, court costs, attorney fees and any other charges incurred in the collection of any balance due. I further understand that a collection fee of 30% will be added to the outstanding balance should my account be placed for collection.
Cancellation/No Show Policy
We understand there may be times when you miss an appointment due to emergencies or obligations to work or family. However, you must call the office prior to your appointment time to cancel or reschedule your appointment. I understand if I miss an appointment without canceling 24 hours in advance I will be charged a $50 no-show fee.
I have read the above policy regarding my financial responsibility to Gold Coast Podiatry, PC for providing medical services to me or the above named patient. I certify that the information is, to the best of my knowledge, true and accurate. I authorize my insurer to pay any benefits directly to Gold Coast Podiatry, PC. I understand that any amount remaining after such payment has been made by my insurance carrier becomes the patient’s responsibility.