I UNDERSTAND AND AGREE TO THE FOLLOWING:
I am responsible for the cost of all health care provided to me by The Foot and Ankle Center. The Foot and Ankle
Center Center will, upon request, provide an estimate of the cost of care for the services I am likely to receive,
with the understanding that such amount is only an estimate and the actual cost of care may be lower or higher.
If I have health insurance, I must pay any deductibles and co-payments at the time services are provided. If The Foot
and Ankle Center is contracted with my insurance company, The Foot and Ankle Center will, as a service to me, bill
my insurance company directly and I hereby assign all insurance reimbursement payments to The Foot and Ankle Center.
I will be responsible for the full cost of my care if insurance coverage is denied and for all amounts not paid by
my insurance company. Such amounts will be due upon my receipt of a bill or statement from The Foot and Ankle
Center. I will be responsible to pay any amount that is not paid by my insurance company even if my treatment was
pre-authorized by The Foot and Ankle Center and/or my insurance company. If The Foot and Ankle Center is not
contracted with my insurance company (e.g. travel insurance) or if a third party may be responsible to pay for my
care (such as in an automobile accident), the account balance will be billed to me in full. I must seek
reimbursement from the insurance company or third party.
If my account is referred to a collection agency, I agree to also pay late charges, interest, reasonable attorney
fees and collection costs.
I certify that all information I provide The Foot and Ankle Center for the purpose of applying for reimbursement
under the Social Security Act is correct and I authorize all holders of my medical and other information to release
such information to the Social Security Administration, its intermediaries and carriers for such purposes. I request
that authorized benefits for services provided by The Foot and Ankle Center be paid to The Foot and Ankle Center on
By Signing below, I agree that I have read this form and/or had it explained to me. I have asked any questions about
any part of the form that is unclear to me, understand the answers, and agree to the terms stated. If I am signing
on behalf of a patient, whether as the patient’s parent, guardian, or other representative, I am authorized to sign
on behalf of the patient.