Please Read and sign below:
I authorize the Bluegrass Foot Center and its doctor, to examine and treat me, and for them to bill my insurance company. Payment should be made directly to the Bluegrass Foot Center.
I understand that my insurance may require certain referrals or that a physician be within a certain provider network, and that any noncompliance of these restrictions may result in reduced or eliminated benefits.
I realize that I am responsible for payment of all fees incurred for my care although I may have insurance that may cover all or part of the cost of such care. I understand that i am responsible for any charges that may be applied to my insurance deductible, coinsurance, or services not covered by my policy. I agree to pay for any collection fee, court costs, attorney and legal fees if it becomes necessary in collecting any outstanding balance.
I authorize the Bluegrass Foot Center to release any information or records acquired in the course of my examination or treatment to my insurance company or other medicla professionals as necessary for my care. This authorization shall remain in effect until it is revoked by me.