DEALING WITH MEDICARE AND THEIR RULES

Medicare covers some medical/surgical services and does not cover others. We will file your Medicare for covered services. Medicare will pay 80% of the charges of which they approve after a $240 yearly deductible has been paid. It will be your responsibility to pay any unmet deductibles. If you have companion insurance (supplement to Medicare), we will file for the remaining 20% of the covered services. You will be billed for any REMAINING balance that your supplement does not pay or if you do not have a Medicare supplement.

Any charges that are for services not covered by Medicare are due and payable at the time of service.

Currently, Medicare Part B will not pay for routine foot care which includes nail trimming, corn or callus trimming, and custom shoe insets and surgical shoes. Also, Medicare will not pay for subluxation (Q74.2) and treatment of flat feet (Q66.50).

The following services are not covered by Medicare. You agree that you have been informed before the services are rendered and that you agree to be responsible for payment of these services as provided.

Service Code	Procedure Code	Estimated Charge
L3211	Surgical Shoe	$30.00
11055-11057	Corn or Callus Paring	$45.00 - $75.00
S0390	Non-covered Foot Care	$50.00
29540	Ankle/Foot Taping	$50.00

I agree to be personally and fully responsible for payment of the above services as provided.

APPOINTMENT REMINDER NOTICE

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

A Notice of Privacy Practices is available in the lobby of Sicher Foot Center. I acknowledge that I understand the notice and have the opportunity to read it if I so choose, or I can be given a copy if requested.

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.

Full Disclosure Notice - Sicher Foot Center (Dr. Gerig and Dr. Sicher) has interest in the following business:

Surgery Center of Amarillo LLC

Dr. Brian Sicher. DPM / Dr. Mark Gerig. DPM
19 Care Circle. Amarillo, TX 79124
Office - (806)353-3366/ Fax - (806)353-0165

HIPAA COMPLIANCE

We want to protect your right to privacy, but on occasion, we may need to speak to your friends or family regarding your health.

Please list below the people we may speak with, should it be necessary, regarding your medical condition.

*If not signed by patient, please indicate your relationship to patient

Sicher Foot Center offers a patient portal where you can access your health information from your visit with our doctors. We use IQHealth through Cerner Health where you can have access to your information when you opt in and create an account with your own unique usemame and password. 

If you choose to opt in to use the portal, you will be sent an email from IQ Health with an invitation to join the portal. There will be a challenge question which is ''What is your zip code". Your answer will be your zip code. You will then follow the instructions to set up your account.

** Medicare requires all healthcare providers to offer an electronic portal to provide patients with access to their health records. However, this is not just for Medicare patients. All patients can utilize this portal. Also, Medicare patients are not required to utilize this portal.

*Sicher Foot Center did not create, nor do we control the patient portal. It is a service provided by Cerner Healthcare Solutions, the company we use for our patient electronic health records.