I hereby give Dr. Kristin Titko permission to administer treatment and perform such procedures as may be necessary for the diagnosis and treatment of my foot and/or ankle condition. Also, I hereby authorize the release of any medical information necessary to process my claim. I also authorize payment to the above mentioned doctor from insurance company(ies) for services rendered to me. My permission is given to above mentioned doctor to keep my other medical care providers informed of my medical information, progress, and treatment obtained. I understand that as a courtesy Podiatry of Hamilton, Inc. dba Center for Foot Care will file all insurance claims for me and I am ultimately responsible for payment of all services rendered.

Social History

Payment Policy
Thank you for choosing The Center for Foot Care as your foot care provider. We are committed to providing you
with quality and affordable health care. Please read the following office payment policy and feel free to ask us any questions that you may have. Once you accept this policy, kindly sign in the space provided. A copy will be provided to you upon request.

1. Insurance. We participate in most insurance plans, including Medicare and Medicaid. If you are not insured by a plan we participate with, payment in full is expected at each visit. If you are insured by a plan we participate with but do not have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.

2. Co-payments and deductibles. Payments for service rendered, including copayments and deductibles, are due at time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment at each visit.

3. Non-covered services. Please be aware that some – and perhaps all – of the services you receive may not be covered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of visit.

4. Proof of Insurance. All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your driver’s license and current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim. If required, obtaining the proper referral from your Primary Care Physician is your responsibility. Patients presenting to our office without a valid referral will be asked to pay in full.

5. Claims submission. We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company.

6. Coverage changes. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits.

7. Forms and Documents. It is our policy to charge $25.00 for completion of all forms, such as disability applications, FMLA papers, etc.

8. Fees. Our fees are representative of the usual and customary charges for our area.

9. DME Coverage. Prior authorization is obtained for DME, but this is not a guarantee of payment. Your insurance will make the final determination of eligibility, allowances, plan limitations and disposition after claim is received. This may become patient responsibility. If you have additional questions regarding coverage, please contact your insurance company.

Thank you for understanding our payment policy. Please let us know if you have any questions or concerns.

I have read and understand the payment policy and agree to abide by its guidelines:

1. RELEASE OF PROTECTED HEALTH INFORMATION

I authorize Center for Foot Care to release information to the following individual(s) (please provide name, relationship and contact number):

2. ACKNOWLEDGE RECEIPT OF THE NOTICE OF PRIVACY PRACTICE

Copies of Notice of Privacy Practice are available when you arrive at the office.

2. . E-MAIL DISTRIBUTION WAIVER

WAIVER OF PRIVACY RIGHTS: FOR THE PURPOSE OF RECEIVING E-MAIL INFORMATION
It is the policy of the Practice to reserve the confidentiality and privacy of the protected health information of all our patients to the fullest extent permitted by law. Because of our Privacy Policy, this Practice will not use e-mail to send protected health information to our patients or to other third-parties without consent. The Health Insurance Portability and Accountability Act (HIPAA) requires consent to send such information to the email address identified on the patient registration form, where it might be seen by another person and reveal to that other person the protected health information. E-mail is not generally “secure” in the sense that others may have access to it. If you wish to receive your protected health information by e-mail, you must sign this waiver. The patrons under the age of 18 must also have their parent’s consent on this form.

I waive my right to privacy under the Health Insurance Portability and Accountability Act (HIPAA) in order to receive the health care information above by e-mail. I understand that in doing so I relieve the Practice of all responsibilities for unauthorized access of protected health information while in transmission and upon delivery. I have the right to formally revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization.