VALLEY  FOOT  &  ANKLE  CENTER,  INC.

DR.  JONES  HORMOZI,  D.P.M.

18840 Ventura Blvd. Suite #211 Tarzana, CA 91356

867 W Lancaster Blvd. Lancaster, CA 93534

PH: 818-981-1900   |   FAX: 866-254-5997

The  above  information  is  true  to  the  best  of  my  knowledge.  I  certify  that  I  have  insurance  with  the  insurance  company(ies)  disclosed  and  assigned  directly  to  Valley  Foot  &   Ankle  Center  all  insurance  benefits,  if  any,  otherwise  payable  to  me  for  service(s)  rendered.  I  understand  that  I  am  100%  financially  responsible  for  all  charges  whether  or   not  paid  by  my  insurance.  I  authorize  the  use  of  my  signature  below  on  all  insurance  submissions.  Valley  Foot  &  Ankle  Center  may  use  my  health  care  information  and   may  disclose  such  information  to  the  disclosed  insurance  company(ies)  and  their  agents  for  the  purpose  of  obtaining  payment  for  services  and  determining  insurance   benefits  or  the  benefits  payable  for  related  services.

I  understand  that  completing  this  form  is  a  chore.  The  information  I  have  provided  is  true  to  the  best  of  my  knowledge.  I   recognize  that  the  information  I  have  provided  will  help  me  receive  better  care.

1. All co-payments are due at the time of visit. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered a violation of the contract you have with your insurance company. Our office accepts cash, credit and debit cards.

2. Co-insurance and unmet deductibles are due prior to scheduled surgeries and procedures. Once benefits are verified and your financial responsibility calculated, you will be notified of the payment amount and due date.

3. You are 100% responsible for payment of charges for services you receive from our office.

4. In accordance with your insurance member handbook, it is your responsibility to provide accurate insurance information and to present your insurance ID card at the time of your visit. If you do not have insurance or
do not present a valid insurance card, you will be responsible for payment at the time of service. We will provide you with a copy of our billing form so that you can obtain reimbursement from your insurance company.

5. It is your responsibility to ensure that our physicians are in your insurance network.

6. If your plan requires a referral, it is your responsibility to obtain this prior to being seen by our provider.

7. Payment is due for rendered services 10 days from receipt of your billing statement. Outstanding balances must be paid in full prior to any additional visit unless arrangements have been made with our billing department.

8. There is a service fee of $35 for each time a check is returned. The bank may return your check up to three times before considering it nonnegotiable. Your insurance company does not cover this fee.

9. A scheduled appointment means that time has been reserved for you. Cancellations for appointments must be received at least 24 hours prior to the scheduled appointment. Cancellations for scheduled surgery and in-office procedures must be received at least 7 days prior to the scheduled surgery date and time.

10. Patients who fail to keep or cancel a scheduled appointment may be charged a $25.00 No Show Fee. There is a $400.00 cancellation fee for scheduled surgeries & $100.00 cancellation fee for in-office procedures that are cancelled less than 5 business days from the date and time of surgery/procedure unless cancellation is due to insurance denial or medical necessity.

11. Medical records requests must be received in writing at least 72 hours prior to the date needed. Fees for medical records are set depending if patient has an outstanding balance and/or an attorney is requesting on your behalf. Fees must be received prior to record delivery. No more than 5 pages may be faxed.

12. Administrative Services: There is a $10.00 charge for each required Administrative Service, payable prior to service completion. This Administrative Service Fee covers specific administrative services such as forms completion for medical leave and disability (EDD Form and EDD extensions), DMV disabled person placard, and any other administrative items not covered by insurance.

13. HMO/PPO: ALL CO-PAYMENTS ARE DUE AT THE TIME OF YOUR APPOINTMENT (S). We are in-network with most, but not all insurance plans. You are responsible for verifying that Valley Foot & Ankle Center is in-network with your plan. If you are an HMO member, you will not be billed as long as we have a unused & valid referrals. Please note: You must have your referral at the time of the visit or your plan requires that we ask you to reschedule. PPO patients will only be responsible for their remaining deductible amount, co-payments and co-insurance as long as they have verified with their insurance that our physician is in their plan.

14. SELF-PAY: Payment in full is due at the time of service if you do not have health insurance coverage.

I  have  received  this  practices  notice  of  privacy  practices  written  in  a  plain  language.  The  notice  provides  in  detail  the  uses and  disclosures  of  my  protect  health  information  that  may  be  made  by  this  practice,  my  individual  rights  and  the  practices legal  duties  with  respect  to  my  protect  health  information.  The  notice  includes:

• A  statement  that  this  practice  is  required  by  law  to  maintain  the  privacy  of  protected  health information.
• A  statement  that  this  practice  is  required  by  law  to  abide  by  the  terms  of  the  notice  currently  ineffect.
• Types  of  uses  and  disclosures  that  this  practice  is  permitted  to  make  to  each  of  the  followingpurposes:   Treatment,  payment,  and  healthcare  operations.
• Description  of  uses  and  disclosures  that  will  be  made  only  with  my  written  authorization  and  that  Imay  revoke   such  authorization.
• My  individual  rights  with  respect  to  protect  health  information  and  a  brief  description of how I made exercises these rights in relation to:

1. The right to complain to this practice and to the secretary of human health services if l believe my
   privacy rights have been violated, and no retaliatory actions will be used against me in the event of
   such a complaint.
2. The  right  to  request  restrictions  on  certain  uses  and  disclosures  of  myprotectedhealth   information,  and  that  this  practice  is  not  required  to  agree  to  a  requested  restriction.
3. The  right  to  receive  confidential  communication  of  protected  health  information.
4. The  right  to  inspect  and  copy  protects  health  information.
5. The  right  to  amend  protects  health  information.
6. The  right  to  receive  an  accounting  of  disclosures  of  protected  health  information
7. The  right  to  obtain  a  paper  copy  of  the  notice  of  privacy  practices  from  this  practice  upon request

This  practice  reserves  the  right  to  change  the  terms  of  its  notice  of  privacy  practices  and  to  make  new  provisions   effective  for  all  protected  health  information  that  it  maintains.  I  understand  that  I  can  obtain  this  practice  current   notice  of  privacy  practices  upon  request.                                                                                                                                                          

I acknowledge that I was provided a copy of Valley Foot & Ankle Center Notice of Privacy Practices and that I have read (or had the opportunity to read if I so chose) and understand the Notice.

Due to the recent implementation of the Patient Privacy Act (HIPPA), I hereby authorize Valley Foot & Ankle Center to leave messages at my home with family members and/or answering machines regarding the following:

(1) Confirm or Change Appointment,

(2) Results of testing ordered by the physician, and/or

(3) Any pertinent information that may be relative to my care.

I acknowledge that I was provided a copy of Valley Foot & Ankle Center Financial Policy and that I have read (or had the opportunity to read if I so chose), understand and will comply by the policies stated.

I authorize Valley Foot & Ankle Center to view my external prescription history via electronic prescribing services. I understand that prescription history from other multiple unaffiliated medical providers, insurance companies, pharmacies and pharmacy benefit managers may be viewable by my provider and staff at Valley Foot & Ankle Center and it may include prescriptions back in time for several years.

I hereby voluntarily consent to outpatient care by a Valley Foot & Ankle Center Podiatrist, encompassing routine care, diagnostic procedures, examination and medical treatment including, but not limited to, minor surgical procedures, ultrasound, photographs and administration of medications and injections prescribed by the Valley Foot & Ankle Center Podiatrist. I agree to ask questions to clarify treatment should I not understand the treatment plan.

I certify that I have insurance with the insurance company(ies) disclosed and assigned directly to Valley Foot & Ankle Center and its Podiatrists, all insurance benefits, if any, otherwise payable to me for service(s) rendered. I understand that I am 100% financially responsible for all charges whether or not paid by my insurance. I agree that should my account become delinquent and is referred to an attorney or collection agency for collection, I will be charged an additional 33 1/3% of any unpaid balance at the time of referral for all costs of collection and attorney's fees. I authorize the use of my signature below on all insurance submissions.

Valley Foot & Ankle Center may use my health care information and may disclose such information to the disclosed insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.