Dear Patient,

We would like to take this time to welcome you to our office. We will do all we can to make your visit a pleasant one.

We have enclosed several forms, which we ask you to complete in full. Once you have filled out all information, please bring them all to your scheduled appointment.

INSURANCE: Please bring in your insurance cards. Copies will be made and kept in your chart which allows for prompt and accurate processing of your claim. As a courtesy, we will be happy to submit all claims to your insurer. Should your carrier refuse payment, you will be required to pay for all unpaid claims. All deductibles are also the sole responsibility of the patient. Payment in full must be made within 30 days of the billing or a surcharge of $29.00 may be implemented unless other satisfactory arrangements are made. We do offer payment plans.

COPAYS: All copays are required prior to seeing the doctor, which is dictated by your insurance company per your contractual agreement with your insurance carrier.

MANAGED CARE: If your insurance requires a referral from your Primary Care Physician, that is your responsibility. We do not obtain referrals for you.

HISTORY FORMS: We do not treat a toe, a nail, or a foot. We treat people. Please fill out all medical information. Please note the highlighted areas and read carefully. DO NOT WRITE IN yes or no under medical history, check only those which apply. Please check any yes or no responses. Family history, social history, and past surgeries are required information. PLEASE BRING IN A WRITTEN LIST OF ALL MEDICATIONS, PRESCRIPTIONS, OR OVER-THE-COUNTER. Include the dosage, amount per day, and the reason you take it.

X-RAYS: If applicable, please bring in any x-rays and written reports you may have at the time of your visit that pertains to your problem.

This letter has been created to alleviate any potential misunderstandings or miscommunications. Our office is always open to you for any questions or concerns you may have. We hope that your visit with us is a pleasant one. On behalf of Dr. Olson, Dr. Tomassi, Dr. Hess, Dr. Pokabla, and staff, we sincerely thank you.

UNDERSTANDING DEDUCTIBLES, COINSURANCE AND COPAYS

When both you and your health insurance company pay for your health care expenses, it's called cost sharing. Deductibles, coinsurance, and copays are all examples of cost sharing. Understanding how they work will help you know how much you'll pay.

Deductible

A deductible is an amount you pay for healthcare services before your health insurance begins to pay.

How it works: If your plan's deductible is $1,500, you'll pay 100 percent of eligible healthcare expenses until the bill's total is $1,500. After that, you share the cost with your plan by paying coinsurance.

Coinsurance

Coinsurance is your share of the costs of healthcare service after your deductible has been met.

How it works: You've paid $1,500 in healthcare expenses and met your deductible. When you go to the doctor, instead of paying all costs, you and your plan share the cost. For example, your plan pays 70 percent. The 30 percent you pay is your coinsurance. 

Copay

A copay is a fixed amount you pay for healthcare service, usually when you receive the service.

How it works: Your plan determines what your copay is for different types of services, and when you have one. You may have a copay before you've finished paying toward your deductible. You may also have a copay after you pay your deductible, and when you owe coinsurance.

Your insurance card may list copays for some visits.

AUTHORIZATION OF TREATMENT

I the undersigned hereby authorize BayCity Physician to render treatment / therapy to myself deemed medically necessary in order to treat the condition / conditions I have requested from himself or his staff.

LEGAL ASSIGNMENT OF BENEFITS AND RELEASE OF MEDICAL AND PLAN DOCUMENTS

In considering the amount of medical expenses to be incurred, I, the undersigned, have insurance or employee healthcare benefits coverage with the enclosed captioned, and hereby assign and convey directly to BayCity Associate, Inc. all medical benefits, insurance reimbursement, if any otherwise payable to me for services rendered from such doctor. I also admit full disclosure of my deductible, what has been met, if any, and what is currently owed. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments, and understand that these balances are due within 90 days from the date of insurance payment, and or denial, and if outside collections attempts are necessary, I will also remain responsible for all collection and legal fees. I hereby authorize the doctor to release all medical information necessary to process this claim. I authorize any plan for any administrator or fiduciary, insurer, and my attorney to release to such doctor, in order to claim such medical benefits, reimbursements, or any applicable remedies. I authorized the use of this signature on all insurance/employee health benefit claim submissions.

I hereby convey to the above-named doctor to the full extent permissible under the law and under any applicable insurance policies/employee healthcare plan to and claim, chose in action, or other right I may have to such insurance/employee healthcare coverage under my applicable insurance policies and or employee health care plan with respect to medical expenses incurred as a result of the medical services I received from the above named doctor and to the extent permissible under the law to claim such medical benefits, insurance reimbursement and any applicable remedies. Further, in response to any reasonable request for cooperation, I agree to cooperate with such doctor in any attempts by such doctor to persue such claim, chose in action or right against my insurers/employee health care plan, including, if necessary, bring quit with such doctor against such insurers/employee healthcare plan in my name but at such doctor's expenses.

This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I have read and fully understand this agreement.

I. Acknowledgement of Practice's Notice of Privacy Practices

By subscribing my name below, I acknowledge that I was provided a copy of the Notice of Privacy Practices (NPP) and that I have read (or had the opportunity to read if I so chose) and understands the Notice of Privacy Practices (NPP) and agree to its terms.

II. Designation of Certain Relatives, Close Friends and other Caregivers as my Personal Representative

I agree that the practice may disclose certain pieces of my health information to a Personal Representative of my choosing since such person is involved with my healthcare or payment relating to my healthcare. In that case, the Physician Practice will disclose only information that is directly relevant to the person's involvement with my healthcare or payment relating to my healthcare.

III. Request to receive Confidential Communications by Alternative Means:

As provided by Privacy Rule Section 164.522(b), I hereby request that the practice make all communications to me as I have listed below:

1. The above authorizations are voluntary and I may refuse their terms without affecting any of my rights to receive healthcare at the Practice.
2. These authorizations may be revoked at any time by notifying the Practice in writing at the Practice's mailing address marked to the attention of "HIPAA Compliance Officer".
3. The revocation of this authorization will not have any effect on disclosures occurring prior to the execution of any revocation.
4. If you request it, a copy of the information described in this form can be obtained at the front desk.
5. This form was completely filled in before I signed it and I acknowledge that all of my questions were answered to my satisfaction and that I fully understand this authorization form.
6. This authorization is valid as of the date I have signed below and shall remain valid until changed or revoked.

II. My Problem (if applicable) has been present for:

WE ARE PLEASED TO HAVE YOU AS A PATIENT. PLEASE ANSWER THE FOLLOWING QUESTIONS TO THE BEST OF YOUR ABILITY. WE TREAT PEOPLE, NOT PEOPLE.

*The following over-the-counter (OTC) substances affect the blood's ability to clot

I, the undersigned, understand that the above information is necessary to provide tme with the best medical care in a safe, efficient manner.I have answered all questions truthfully and to the best of my knowledge.

(Caregiver, Parent or Guardian, if applicable)

*Positive ROS responses not related to the podiatric problem(s) have been discussed with the patient. The patient has been advised to see their PCP.