ASSIGNMENT OF BENEFITS
I hereby authorize payment to Brian E. Sicher, DPM or Mark A Gerig, DPM. I hereby agree that in the event that payment by a third party for any individual visit exceeds that necessary to cover charges incurred during visit, any coverage may be applied to outstanding charges owed the clinic for other services rendered to myself, my spouse, or legal dependents of myself or spouse at the time.
I acknowledge that I am financially responsible for non-covered services and any unpaid insurance balance over 90 days past due.
I certify that the information given is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration (or its intermediaries or carriers) any information needed for this or related medical claim.
Brian E. Sicher, DPM or Mark A. Gerig, DPM may disclose all or part of this patient's record to any insurance company, physician, clinic, hospital, or laboratory. I understand that the information released may include information pertaining to mental or psychiatric related conditions. A copy shall be valid as the original.
Please be aware that we will file your insurance, but you will be responsible at the time of service for any copay, co-insurance, or unmet deductible or out-of-pocket amounts. Please be aware that most services performed by Dr. Brian E. Sicher, DPM or Dr. Mark A Gerig, DPM are considered surgical procedures* and will be applied to your deductible. Copays are for the office visit codes only, therefore additional payment from the patient is usually required. Please see the receptionist with any questions or an explanation of this statement.
*Incisions made into the skin, categorized by the American Medical Association as a surgical procedure, include but are not limited to: wart removal, ingrown nails, steroid injections, and any incision and drainage procedure. Office visit copays do not apply to these procedures. These procedures are usually subject to a calendar year deductible. Please ask the office staff if you have any questions regarding this matter.
**IT IS YOUR RESPONSIBILITY TO MAKE SURE YOU HAVE A VALID REFERRAL IN PLACE IF YOUR INSUBANCEREQUIRES ONE. Please talk to the receptionist if you are unsure if your primary provider has placed the required referral with your insurance carrier.
**You will be billed for services if a referral is not in place.**
A NO-SHOW FEE OF $80 MAY BE BILLED TO YOU IF YOU DO NOT GIVE AT LEAST 24 HOUR CANCELLATION NOTICE PRIOR TO YOUR SCHEDULED APPOINTMENT.