Dear Patient,

We ask that you please read and sign this form as it concerns you, the patient.

Due to the many changes in insurance policies, it is no longer an easy task to interpret each individual policy, therefore we ask you, the patient to please check with your insurance company regarding your coverage and benefits. It is YOUR responsibility to know YOUR individual coverage, limitations and coordination of benefits. Failure to comply with this suggestion could result in you, the patient, being responsible for all costs incurred. Please remember that your insurance policy is between you and your health insurance company.

If you need a referral/authorization from your insurance company or from your primary care physician (PCP) or from another doctor to be seen in this office, the referral/authorization must be present at the time of your visit. If it is not available, it will be your responsibility to obtain one. Consequently, you will need to reschedule your visit should the referral/authorization not be available. We welcome you to call your insurance company and/or physician and have your referral/authorization faxed to us at (321) 454-9208.

If you have a co-payment or co-insurance, out of pocket expenses, deductibles, services/products not covered by insurance, etc., it must be paid at the time of service.

Please call your insurance company and learn about your coverage. It may save you a lot of confusion and out of pocket expenses.

In case of an emergency, who should be notified?

I, the undersigned, knowing the patient, minor, and or self, certify that the information above is true and correct to the best of my knowledge. I give permission to the physician and staff to administer and perform diagnostic and therapeutic procedures, including, but not limited to injections, as may be deemed necessary in the diagnosis and/or treatment of lower extremity. I understand that no guarantee has been made as to the result of the procedure/treatment. I authorize release of medical information to my doctor, health agency, insurance company, government agency, or worker’s compensation. I request and authorize payment of insurance benefits and/or government benefits made on my behalf to be paid directly to Merritt Island Foot and Ankle, Inc. I assume full financial responsibility for all services rendered, even if I have insurance, and agree to pay if not paid or covered by my insurance within 90 days. It is my responsibility to obtain authorization from my Primary Care Physician or insurance company (if required) prior to services rendered.

Notice to Patient:

We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your health information. Please sign this form to acknowledge receipt of the Notice. You may refuse to sign this acknowledgement, if you wish.

I acknowledge that I have received a copy of this office’s Notice of Privacy Practices.

We cannot discuss your protected health information (PHI) with anyone other than yourself unless you authorize us to do so. Please list below name(s) of the individual(s) you authorize our office to discuss care with. Your PHI may be disclosed to the individual(s) listed below until you notify us otherwise in writing.

I understand that I have certain rights to privacy regarding my protected Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to care out:

• Treatment (including direct or indirect treatment by other healthcare providers and laboratories involved in my treatment)
• The day to day healthcare operation of our practice
• Obtaining payment from third party payers (i.e. insurance companies)

I have also been informed and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA. I understand that you reserve the right to change the terms of the notice from time to time and that I may contact you at any time to obtain the updated copy of the notice.

I understand that I have the right to request restricts on how my protected health information is used and disclosed to carry out treatment, payment, and healthcare operations, but that you are not required to agree to theses requested restrictions. However, if you do agree, you are then bound to comply with these restrictions.

I do understand that I may revoke this consent, in writing at anytime. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.