• PATIENT HEALTH INFORMATION

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  • Medication(s):

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  • PATIENT DEMOGRAPHIC INFORMATION

  • Primary Care Physician Information:

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  • Lone Star Podiatry Patient Payment Policy

  • Thank you for choosing our practice! We are committed to the success of your medical treatment and care. Please understand that payment of your bill is part of this treatment and care.

    For your convenience, we have answered a variety of commonly-asked financial policy questions below. If you need further information about any of these policies, please ask to speak with a Billing Specialist or the Practice Manager.

  • How May I Pay?

  • We accept payment by cash, check, VISA, Mastercard, or Discover

  • What is My Financial Responsibility for Services?

  • Your financial responsibility depends on a variety of factors, explained below.

  • Office Visits and Surgeries

  • If you have… You Are Responsible For: Our Staff Will:
    Commercial Insurance
    Also known as indemnity,
    “regular” insurance
    Payment of the patient responsibility for all office visits, x-ray, injections,
    and other charges at the time of office visit.
    Call your insurance company ahead of time to determine
    deductibles and coinsurance. File an insurance claim as a
    courtesy to you.
     HMO & PPO plans with which
    we have a contract
    If the services you receive are covered by the plan: All applicable
    copays and deductibles are requested at the time of the office visit. If the services you receive are not covered by the plan: Payment in full is requested at the time of the visit.  
     Call your insurance company ahead of time to determine
    copays, deductibles, and non-covered services for you & file an insurance claim on your behalf 
     HMO with which we are not contracted Payment in full for office visits, x-ray, injections, and other charges at
    the time of office visit.
     Provide the necessary information for you to complete and
    file your claim directly with the insurance company
     Point of Service Plan or Out Of Network PPO  Payment of the patient responsibility – deductible, copay, noncovered services – at the time of the visit.  Call your insurance company ahead of time to determine out of network benefits, copays, deductibles, and noncovered services & file an insurance claim on your behalf
     Medicare  Any services not covered by Medicare are requested at the time of
    the visit.
    If you have Regular Medicare as primary, and also have secondary
    insurance or Medigap:
    No payment is necessary at the time of visit
     File the claim on your behalf, as well as any claims to your
    secondary insurance. 
     Office Appointment No Show  Letting us know 24 hours in advance if you can’t make an office
    appointment. Paying a $35 administrative fee if you aren’t able to
    cancel 24 hours in advance.
     Confirm your appointment 1-2 days in advance of your appointment. 
     Procedure/Surgery
    Scheduling
     We have a $100 deposit which is applicable to your deductible/coinsurance. It is non-refundable if you reschedule (more than once) or cancels less than 48 hours in advance.  Our staff will handle all your insurance authorization and
    questions. They will also coordinate with the surgery center
     No insurance  Payment in full at the time of the visit.  Work with you to settle your account. Please ask to speak
    with our staff, if you need assistance.
  • • I have read, understand, and agree to the above Financial Policy. I understand that charges not covered by my insurance company, as well as applicable copayments and deductibles, are my responsibility.
    • I authorize my insurance benefits be paid directly to Andrew Cassidy, DPM
    • I authorize Andrew Cassidy, DPM to release pertinent medical information to my insurance company when requested, or to facilitate payment of a claim.

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  • Andrew Cassidy, DPM

    Acknowledgment of Receipt of Privacy Notice

    I have been provided with a Notice of Privacy Practices that provides me a more complete description of the uses and disclosures of certain health information. I understand Andrew Cassidy, DPM, reserves the right to change their Notice of Privacy Practices. I may request a copy of the updated Notice of Privacy Practices by calling my physician’s office or requesting a copy in person at my appointment.

    The duration of this authorization is indefinite unless otherwise revoked in writing. I understand that requests for medical information from persons not listed below will require a specific authorization prior to disclosure of any medical information.

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  • The following names are of people I would like to be involved in or have access to my protected health information on a routine basis. I give permission for Andrew Cassidy, DPM, to share my protected health information with:

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