Who is your primary care physician and what other doctors treat you regularly?

List your primary pharmacy (name and location) - This is where we will send any prescriptions

The US HITECH Act requires us to ask the following questions:

I have answered the above questions to the best of my ability. By typing your name below, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement.

Thank you for choosing our office as part of your health care team. In our effort to provide personalized care in the most efficient and economical manner possible, we are providing to all of our patients this copy of our Financial Policy. We ask that you take a few moments to read our Financial Policy and sign below.

Insurance Coverage

Your insurance policy is a contract that exists between you and your insurance company. Our relationship is with you, the patient, and not the insurance company. If you have questions about your coverage, please call the phone number provided on the back of your insurance card. New insurance companies are continually forming and existing insurance companies are rapidly changing. It is your responsibility to know the specifics of your policy (referral requirements, in and out of network physicians and facilities, etc.). Most private insurance policies (non Medicare/Medicaid) plans now have deductibles, copayments, coinsurances, maximums and limitations (out of pocket expenses). If your annual out of pocket expenses have not been met, you will be required to pay a $150 deposit at the time of your visit. This will be applied to your account and a statement will be sent reflecting any additional fees owed following response from your insurance carrier. These measures maintain compliance with the “No Surprise Act”. In lieu of a deductible deposit, a valid credit card will be required and stored securely. Upon claim response from your insurance, you will receive a statement, if the statement goes unpaid your credit card will be charged and a detailed statement will be provided along with a paid receipt.

We rely on you to inform us of all insurances in effect and to notify the office immediately of any changes with your insurance. If you do not inform us of changes, you will be responsible for the services rendered. When multiple policies exist, it is the patient’s responsibility to inform us which policy is the primary plan. If we are not provided ALL insurance information at the time of service, you will be responsible for paying Elite Foot & Ankle directly and then submitting for reimbursement from your insurance company. As a courtesy our staff performs eligibility and benefit checks on the day of service (as requested from insurance).

Although we try our best, due to the constant changes in insurance policies and coverage, it is NO LONGER possible for us to interpret each individual policy. It is your responsibility to know your coverage and to make sure we are contracted with your particular plan. Please check your coverage for anticipated services prior to your appointment. Because your insurance policy is a confidential agreement between you and your insurance company, we are rarely privileged to know what services are covered on your particular plan.

The cost of custom orthotics, boots and other DME is NON-REFUNDABLE and MAY NOT BE RETURNED for a refund because these are medical devices and orthotics are a custom made item.

 

All charges are the responsibility of the patient. We will bill your insurance company as a courtesy, but any services not covered by your policy are the patient’s responsibility.

HIPAA Compliance Patient Consent Form

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that:

• Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
• The practice reserves the right to change the privacy policy as allowed by law.
• The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions
• The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease
• The practice may condition receipt of treatment upon execution of this consent.