IF WORK RELATED OR AUTO ACCIDENT   COMPLETE BELOW

I UNDERSTAND THAT I AM RESPONSIBLE FOR MY BILL.  I AUTHORIZE NORTHWEST FOOT AND ANKLE CENTER TO ACT AS MY AGENT IN HELPING OBTAIN PAYMENT FROM MY INSURANCE COMPANIES.  I AUTHORIZE PAYMENT DIRECTLY TO NORTHWEST FOOT AND ANKLE CENTER.  I AUTHORIZE THE RELEASE OF INFORMATION NECESSARY TO COLLECT ANY PAYMENTS TO ALL INSURANCE COMPANIES. I FURTHER AUTHORIZE RELEASE OF MEDICAL INFORMATION TO ANY AND ALL PHYSICIANS INVOLVED IN MY CARE.  I PERMIT A COPY OF THIS AUTHORIZATION TO BE USED IN THE PLACE OF ITS ORIGINAL.  I AUTHORIZE THE USE OF SIGNATURE ON FILE TO BE USED ON ALL OF MY INSURANCE SUBMISSIONS.  I UNDERSTAND THAT I AM RESPONSIBLE FOR NOTIFYING THE OFFICE OF ANY PRECERTIFICATION, REFERRALS, OR CHANGES NEEDED FOR MY INSURANCE.

PLEASE COMPLETE THE FOLLOWING: (IF ANSWER IS NONE PLEASE INDICATE)

DO YOU:

I CERTIFY THAT THE ABOVE INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE. I WILL NOT HOLD MY PHYSICIAN OR ANY MEMBERS OF HIS/HER STAFF RESPONSIBLE FOR ANY ERRORS OR OMISSIONS THAT I HAVE MADE IN THE COMPLETION OF THIS FORM.

Thank you for choosing Northwest Foot and Ankle Center, PS for your podiatry needs. We are committed to the successful treatment of your condition.

PUNCTUALITY IS APPRECIATED BY OUR OFFICE. IF YOU ARE MORE THAN 15 MINUTES LATE TO YOUR APPOINTMENT THEN IT MAY BE NECESSARY TO RESCHEDULE IT TO ANOTHER DAY.

PRESCRIPTIONS WILL NOT BE REFILLED AFTER 4:00 PM, OR ON WEEKENDS, EXCEPT FOR EMERGENCY CASES. FOR MEDICATION REFILLS, PLEASE CALL YOUR PHARMACY 48 HOURS IN ADVANCE TO HAVE THE REFILL REQUEST FAXED TO OUR OFFICE. IF YOUR MEDICATION IS IN THE NARCOTIC FAMILY, IT WILL REQUIRE A PHYSICAL COPY OF THE PRESCRIPTION

Durable Medical Equipment– Our office will assist in determining coverage for Durable Medical Equipment (braces, splints, boots, orthotics, etc.) as needed. Any item not covered by insurance is deemed patient responsibility.

Non-Covered Charges (OTC)– Some treatment options are not covered by any insurance company; patient is responsible for these charges.

Self-Pay (NO insurance)– Payment is due at the time of service; patient will be provided a good faith estimate at the end of your appointment.

Insurance – It is the responsibility of the patient to provide our office with the most update insurance information, so we can check benefits and coverage prior to the appointment. All copays, deductibles, and/or co-insurance are due at time of service. Our office will provide an estimate at check out, please note this is ONLY an estimate and patient will be responsible for any additional patient responsibility once insurance has processed claims.

Returned Checks – Any returned check is subject to a $45.00 bank fee.

Referrals – If your insurance requires that you obtain a referral from your Primary Care Physician, it is your responsibility to ensure that our office receives the referral prior to your visit. If a referral is not in place, you will be responsible to pay in full at the time of service.

Workers’ Compensation / Auto Accident Claims –We require that private insurance is on file as a backup, in the event there is an issue with the claim. Before billing them, we will inform you. We do not bill 3rd party claims.

Past Due Accounts – Payment is due upon receipt of a statement for any additional patient responsibility after insurance has processed claims. A statement will be sent every 30 days. If you then fail to make payments after 90 days and you have not made financial arrangements, your account may be referred to a professional collection agency,

Payment Methods – We accept personal checks, Visa, MasterCard, American Express, Discover, Apple Pay, cash, and money orders.

Should you have any questions regarding any aspect of your financial status with our office, please feel free to contact our Billing Team at (425) 277-3668.

We keep a record of the health care services we provide you.  You may ask to see and copy that record.  You may also ask to correct that record.  We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so.  You may see your record or get more information about it by contacting our office here at Northwest Foot and Ankle Center, PS.  Our Notice of Privacy Practices describes in further detail how your health information may be used and disclosed, and how you can access your information.

By my signature below, I acknowledge receipt of the Notice of Privacy Practices.

I further acknowledge there were no promises of compensation for such use of medical photos, videos and/or media taken by Northwest Foot and Ankle Center, PS.

By signing below, I confirm that I understand and agree to this consent form.

This form will be retained in your medical record.

Updated: June 2024