Authorization for Assignment benefits
HIPPA Authorization (Privacy)
I hereby give my consent for William D. Fishco, D.P.M. to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO).
I have a right to review the Notice of Privacy Practices prior to signing this consent. William D. Fishco, D.P.M. reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to William D. Fishco, D.P.M. Privacy Officer at 41818 N Venture Dr #110, Anthem, AZ 85086.
With this consent, William D. Fishco, D.P.M. may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory results among others.
With this consent, William D. Fishco, D.P.M. may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential.
With this consent, William D. Fishco, D.P.M. may e‐mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that William D. Fishco, D.P.M.restrict how it uses or discloses my PHIto carry out TPO.
However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.
By signing this form, I am consenting to William D. Fishco,D.P.M. use and disclosure of my PHI to carry out TPO.
I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, William D. Fishco,D.P.M. may decline to provide treatment to me.
Dear Patient:
We would like to take this opportunity to welcome you to our practice and thank you for choosing William D.Fishco, D.P.M.,P.C.to provide your foot and ankle care. We appreciate your trust and look forward to keeping your feet healthy.
As part of your service, we try to contain the rising cost of healthcare. In an effort to do this, we have implemented this Financial Policy which we ask you to read and sign. You may receive a copy for your records if you so desire.
As a courtesy to you, our billing service (1&8 Billing Services, LLC) will submit your insurance claim(s] for treatment rendered at this office. Please be advised that your insurance policy is a
contract between you and your insurance company. We are not a party to that contract. If you ever have any questions regardingyour coverage and /or benefits, please contact your insurance company. Ultimately, you are responsible for all costs incurred during treatment with the exception of insurance contracted adjustments. These adjustments are determined by the contract with the doctor and the insurance company. lf your insurance does not accept assignment of benefits, in other words, if they pay you rather than the doctor, payment must then be made in full at the time of service. In such instances, we will submit the claim on your behalf.
Although we do accept assignment of insurance benefits, we require payment of any copayments due at the time of service. We accept cash, credit/debit cards. lf you have any deductible or co-insurance amounts to be met, you will be billed once your insurance has processed and paid their
portion of the claim.
Full payment is due at the time of service. We accept cash, debit, and credit. In some instances a payment plan may be made for some patients on a case-by-case basis with our billing service. While we try to accommodate all of our patients, our billing service does maintain strict guidelines regarding payment plans.
You will receive a statement once a month only if you have a balance owing. Failure to pay a balance by the third billing statement will result in your account being turned over to "collection status." The doctor will nolonger beable to continue treatment until the balance is paid or special payment arrangements are made. Please note that there is a $25 fee plus balance on all returned checks.
In order to refrain from raising our fees, we must control our costs and maintain efficiency in the business aspect of our practice. We are dedicated to providing you and your family with the best possible podiatric care. We will also attempt to accommodate you whenever possible. lf you have any questions, please contact our office and we will be happy to discuss them with you. Thank you for your understanding.
I have read the Financial Policy and understand and agree to its terms.
Please sign your name in the area below