I ACKNOWLEDGE THAT I WAS PROVIDED A COPY OF THE NOTICE OF PRIVACY PRACTICES AND THAT I HAVE READ (OR HAD THE OPPORTUNITY TO READ IF I SO CHOSE) AND UNDERSTOOD THE NOTICE. I HEREBY AUTHORIZE SUCH MEDICAL, TREATMENT, AND DIAGNOSTIC TESTS AS MAY BE RECOMMENED BY THE ANP FOOT & ANKLE CLINICS, DOCTORS AND STAFF TO EXAMINE, DIAGNOSE AND TREAT MY PODIATRIC AILMENTS. I UNDERSTAND THERE IS NO WARRANTY OF RESULT OR CURE. THIS CONSENT WILL REMAIN IN EFFECT UNTIL I WITHDRAW W MY REQUEST IN WRITING.
I HEREBY REQUEST THAT THE PAYMENT OF AUTHORIZED INSURANCE/MEDICARE BENEFITS BE MADE DIRECTLY TO THE ANP FOOT & ANKLE CLINICS ON MY BEHALF FOR ANY SERVICES PROVIDED TO ME BY ANP FOOT & ANKLE CUNICS. I AUTHOR IZE ANP FOOT & ANKLE CLINIC’S DOCTORS AND STAFF TO RELEASE ANY MEDICAL OR OTHER INFORMATION ABOUT ME, NEEDED TO DETERMINE THE BENEFITS FOR THE SERVICES, TO THE HEALTH CARE FINANCING ADMINISTRATION AND OR MY HEALTH INSURANCE COMPANY AND ITS AGENTS.
I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES WHETHER OR NOT PAID BY INSURANCE; AND I AM SUBJECT TO ANY LATE OR SERVICE FEES FOR ANY UNPAID BALANCE. I AUTHORIZE THE USE OF MY SIGNATURE ON ALL INSURANCE SUBMISSIONS.