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Please complete the following form and answer all questions before arriving for your appointment.
Be sure to include your insurance information.We'll see you soon!
To preserve the best possible relationship with you, our patient, and to prevent any misunderstanding, we hope the following explanation of our office policy regarding insurance and payment for services is helpful. 1.) We expect and appreciate payment for office visits at the time of service. We will accept cash, check, MasterCard, Visa, or debit cards. 2.) For any insurance plan that requires authorization from a primary care physician, (e.g. HMO, PPO, etc.), it is your responsibility, (as patient or guardian), to be sure that this office receives all necessary referrals or authorizations PRIOR to treatment. If the insurance carrier denies any charges due to lack of referral authorization, you, (the patient), are responsible for all charges incurred. 3.) If any type of supplies are dispensed during the course of treatment, (e.g. arch supports, accommodative pads, creams, surgical shoes, etc.), payment is due at the time of service. We cannot bill you or the insurance company for these supplies. 4.) I have read, and understand and agree to the above office policies and understand that I am financially responsible for any balance due on my account. 5.) I hearby give permission to the Boston Common Podiatry to administer treatment and to perform such procedures as may be deemed necessary in the diagnosis and/or treatment of my foot condition and authorize disclosure of medical information to assist in processing my insurance claim and to communicate with treating physicians. Furthermore, I assign all payment of medical benefits provided by my insurance company policy for medical/surgical care to Boston Common Podiatry. 6.) You are responsible for giving the office 24 hour notice of cancellation. If you cancel or miss an appointment, you will be charged a fee of $50 which will need to be paid before you can reschedule or make a new appointment. The Office does have a date and time-stamp voicemail system when messages are left after hours.
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. The NPP can be found at the following link: https://bostoncommonpodiatry.com/images/hippa.pdf
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.
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 to 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.
Please ensure you have completed all mandatory fields on this form (indicated with an (*) asterisk next to the field) and please wait until our thank you page loads to ensure the form was successfully submitted otherwise your data will be lost.
