Patient Information Form

I certify that the above information is true and correct to the best of my knowledge. I hereby give permission for Family Foot & Ankle Clinics of WI to administer and perform such procedures as may be deemed necessary in diagnosis/treatment of my feet/ankles. I authorize the release of any information to my insurance company and any medical information necessary to process any claim and I request payment of insurance benefits due to Family Foot & Ankle Clinics of WI to be paid directly to Family Foot & Ankle Clinics of WI.
I hereby give my permission for Family Foot & Ankle Clinics of WI to forward any pertinent medical information to my primary or referring physician for continuity of care. I permit a copy of this authorization to be used in place of the original. This authorization may be revoked at any time by either myself or my insurance company in writing. The above information is true and I will notify Family Foot & Ankle Clinics of WI of any changes.

Patient Contract

Payment is expected at time of service. EXCEPTIONS to include: Medicare patients, PPO and HMO/POS members.
As a courtesy, we will be happy to bill your primary and secondary insurance company on your behalf. It is up to each patient to know the rules and limitations of your policies.
If your insurance company does not make the payment you expect, it is up to the policyholder to contact the insurance company. Our office will supply any documentation necessary to expedite the handling of the claim.
Any balance past 90 days is considered delinquent, and will be put to patient responsibility. It is your responsibility to contact your insurance company if payment is delayed. Most insurance companies DO NOT COVER SUPPLIES given in an office setting; payment will be due at the time of service for such supplies (ABN SIGNATURE WILL BE REQUIRED). We will attempt to bill these supplies to your insurance company and refund any money received to you.
If you need to cancel an appointment, please notify us at least 24 hours in advance. We will gladly reschedule your appointment.

Financial Policy

We are committed to providing you with the best possible care and are pleased to discuss our professional fees with you at any time. Your clear understanding of our Financial Policy is important to our professional relationship. Please ask if you have any questions about our fees, financial policy, or your financial responsibility.
FOR BILLING PURPOSES: it is the patient’s responsibility to update any changes such as Address, phone, and insurance company.
COPAYMENTS: By law we must collect your carrier designated copay at the time of service.
COINSURANCE/DEDUCTIBLE: are patient responsibility. A billing statement will reflect such charges deemed patient responsibility.
REFERRALS: if your insurance policy requires a referral from your PCP, it is your responsibility to obtain it prior to your appointment. If you do not obtain a referral, you will be responsible for all charges.
SELF PAY PATIENTS (NO INSURANCE): Payment is REQUIRED at the time of service.
MEDICARE: We will submit to Medicare for the entire Medicare allowed amount. The patient will be responsible for the deductible and the 20% co-insurance, which can be billed directly to secondary insurance if applicable.
DELINQUENT ACCOUNT: Any account after 90 days with no payment. After 90 days bill will be sent to 3rd party collection agency with late fees.
LATE FEES: Patient will be charged a late fee for non-payment if your account has been transferred to a 3rd party collection company. Fees will reflect cost accessed from 3rd party collection company and time taken processing account.
WE ACCEPT CASH, CHECK, MASTERCARD, VISA, and DISCOVER.

Acknowledgement of Receipt of Notice of Privacy Practice

I acknowledge that I was provided/offered a copy of the Notice of Privacy Practices from Family Foot & Ankle Clinics of WI and that I have read (or had the opportunity if I so chose) and understand the notice.
I have read & understand the above Patient Contract & Financial Policy/Confidential Communications for Family Foot & Ankle Clinics

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