Intake Form

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. Professional services are rendered and billed directly to your insurance carrier; however you, the patient/guardian, are directly responsible for services rendered by the doctor. A health insurance policy is a contract between you (the patient or subscriber) and your insurance carrier. You MUST notify this Office of any changes to your insurance policy including policy termination, changes in co-payments or a new insurance policy. If for any reason the insurance carrier denies charges, payments for any services rendered will become the responsibility of the patient/guardian.

All office visit charges and co-pays are due at the time services are rendered. It is the patient who is responsible for any and all financial aspects of services rendered. There will be a charge for returned checks, missed appointments without 24 hours notice and completion of any forms. I agree to pay for all deductibles, co-pays, non-covered services and any portion of covered services not paid in full by my insurance plan and understand that such payments are due at the time of service or immediately upon presentation of the bill. I hereby name Greater Texas Foot & Ankle Specials (GTFAS) as my assignee. I instruct my health care benefits plan administrator, i.e. PLAN to pay GTFAS directly for all professional and medical services provided by GTFAS through the means of electronic funds transfer(s) (EFT) or by check(s) made payable to and mailed to GTFAS. I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS CLAIMS.

The above information is correct to the best of my knowledge. I understand that throughout my treatment, I am responsible for notifying the physician and/or medical staff of any and all updates to the information listed above. I also give permission for photographs of my feet to be taken that are to be kept as part of my medical record only. They will not be published as part of medical research or disbursed in any way without my permission.

I acknowledge that I was provided a copy of the Notice of Privacy Practices for Greater Texas Foot & Ankle Specials and I have read (or had the opportunity to read if I so choose) and understood the Notice.

COPAYMENTS: It is a requirement of your insurance company that we collect your co-pay. Payment is required before meeting with the doctor.

DEDUCTIBLES & CO-INSURANCE: If you have a high deductible plan (Remaining amount greater than $250.00) OR a plan with no deductible and high out of pocket (remaining amount greater than $250.00), we may collect a $125 deposit to apply towards your deductible and coinsurance. Any remaining balance after submission to your insurance company is your responsibility.

SELF-PAY (for non-covered products and services and for patients without insurance coverage): Full payment is due at time of service. A down-payment will be required before seeing the doctor. At a minimum, an evaluation and management fee will be charged. Additional procedures/services may be recommended by the doctor. You will be informed of these charges before proceeding with treatment

REFERRAL: If your insurance plan requires a referral from your primary care doctor, this will be required at the time of your visit. Without a referral available, we may need to reschedule your appointment.

NO SHOW (failure to present for your appointment): 24 hours-notice is required for cancellation of your appointment and failure to do so will incur a $50 fee. Failure to provide 24 hours-notice for a scheduled office procedure will incur a $100 fee.

SURGERY CANCELLATION: : Failure to provide 5 business-days notice before surgery will incur a $500 fee.

BALANCES/COLLECTION FEES: If payment of an outstanding balance is not received within 30 days from the postmark date of a mailed statement or e-statement time stamp, a $10 re-billing fee may be added to each additional statement. Our patient portal offers the ability to view statements and submit payments conveniently and securely. Patients with balances more than 90 days overdue will be turned over to collections and a $35 administrative fee will be applied.

FMLA/DISABILITY/MEDICAL RECORDS: There is a $25 charge for having the doctor complete these forms. Requested forms will be completed within 72 hours of diagnosis and care plan. There is a $15 fee to obtain a copy of your medical records.

I have read and understand these financial policies.