The office of Dr. Mistretta understand that medical information about you and your health is personal and we are committed to protecting that information. With that understanding, we will use and disclose your health information for the following purposes: to treat you, to assist other health care providers in treating you, to allow insurance companies to process insurance claims for services rendered to you, to obtain payment for services rendered to you and for certain limited operational activities such as quality assessment, licensing, accreditation and training of students. We will not use or disclose your health information without your written authorization, except as stated in more detail in the Notice of Privacy Practices. We reserve the right to change this notice and will post a copy of the current notices in effect in our facility.

In addition to the allowable disclosures described in the Notice of Privacy Practices, if you would like to authorize the disclosure of your protected health information to another person(s) please specify by answering the questions below. In regards to your protected health information, are we allowed to speak with (please check):

I acknowledge that I was provided a copy of the Notice of Privacy Practices and have read (or had the opportunity to read if I so chose) and understood the Notice.

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In an effort to accommodate our patients, Affiliated Foot & Ankle participates with most insurance plans. Although we are pleased to provide services to our patients, it is impossible for our office staff to be aware of the specific benefits and requirements of each and every plan. There may be limitations under your plan on procedures, supplies, durable medical goods, numbers of office visits, laboratories you may use, referrals and authorizations for certain procedures. We ask that you please be familiar with your insurance contract regarding services, exclusions, and expiration dates for referrals. Unfortunately, if you do not inform us of special guidelines and limitations of your plan, and we subsequently order or perform services or procedures, these may be considered non-covered and will not be paid by the insurance company. Any service determined to be non- covered by your plan will be your responsibility. You are responsible for any, and all co-payments, deductibles, non-covered services, procedures, supplies, and coinsurances. Co-payments are due at the time of service. Once your insurance carrier has processed your insurance claim, you are responsible for ALL remaining balances. A statement will be sent and you will be responsible to remit ALL balances in full. Any special financial arrangements must be approved in writing from our business office. LATE FEE: There is a $25.00 late fee for all unpaid balances after 60 days past the date of service.

A fee of $30.00 will be assessed on any checks returned for insufficient funds. If we find it necessary to take collection action on your outstanding balance, you will be assessed an additional 30% collection fee to that amount or a minimum of $30.00

 Our office requires 24 hours notice if you are unable to make your appointment. Please notify us as soon as you are aware of any schedule changes. There will be a $35.00 fee for not complying with this policy. Your courtesy is deeply appreciated so that we may serve you and other patients more efficiently.

I have read theabove payment policy, understand the contents thereof, and agree by the terms set forth.