When necessary, we will contact you at your phone#, cell phone#, and if necessary Emergency Contact phone#. If we are unable to reach you we will leave a voicemail.
TO THE BEST OF MY KNOWLEDGE, I HAVE ANSWERED THE QUESTIONS ON THIS FORM ACCURATELY. I UNDERSTAND THAT PROVIDING INCORRECT INFORMATION CAN BE DANGEROUS TO MY HEALTH. I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO INFORM THE DOCTOR AND OFFICE STAFF OF ANY CHANGES IN MY MEDICAL STATUS.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES (HIPAA)
I ACKNOWLEDGE THAT I WAS OFFERED A COPY OF THE NOTICE OF PRIVACY PRACTICES AND THAT I HAVE READ (OR HAD THE OPPORTUNITY TO READ IF I SO CHOSE) AND UNDERSTAND THE NOTICE.IF YOU WOULD LIKE TO READ A COPY OF THE NOTICE OF PRIVACY PRACTICES, PLEASE ASK AT THE CHECK-IN DESK.
Thank you for choosing Southside Foot Clinic as your health care provider. We are committed to the successful treatment of your condition. Your clear understanding of our financial policy is important to our professional relationship. Please call our office if you have any questions at 317-882-9303.
MedicareWe are participating physicians with Medicare. This means that you will be responsible for 20% of the approved Medicare fee, the yearly deductible (if applicable) and full payment of any non covered services. There may be occasions when you will be asked to sign a waiver for any non covered services that may not be covered under these plans.
HMO/PPO/EPA/HDHPWe are members of most, but not all plans. You are responsible for verifying that the physician is in your network. HMO members – please note:You must have your referral at the time of your visit or your plan requires that we ask you to reschedule. You are responsible for referrals and any non-covered services.Self Pay - Full payment is due at the time of service unless prior arrangements have been made.
DISCLOSURE OF FINANCIAL INTERESTPursuant to Ind. Code. Ann. § 25-22.2-11-3. Indiana law requires physicians make the following disclosures to a patient when they refer a patient to a health care entity in which the physician has a financial interest. In the event that you undergo surgery in an ambulatory surgery center, a separate charge will be made by that facility. Your podiatric physician at the Southside Foot Clinic may have a financial interest in; a surgery center where you will be having your surgery, Franciscan Surgery Center or Community Surgery Center; a compounding pharmacy, Health Scripts Specialty Pharmacy; and Foot and Ankle surgical implant company, Paragon 28. You may choose to be referred to another health care entity.
Usual and Customary Rates(UCR)We are committed to providing you the best treatment possible. Our charges are “usual and customary” for our area. If we do not have a contract with your insurance company, you are responsible for payment in full, regardless of any insurance company’s arbitrary determination of UCR.
Anthem HIP patientsWe are not part of this program within the Anthem network. This means that if you would like to be seen here, payment is due in full at time of service. Since we are out-of-network with this program, we cannot bill Anthem for your claim. You must understand that you will not be reimbursed by them, ifseen in our office.
Financial AgreementI understand that if the office agrees to bill insurance as a courtesy, I must submit information as needed to ensure that payment for servicesrendered is received. I understand that I am ultimately responsible for payment of allservices. I will pay any unpaid balance by cash, check, or credit card (VISA/MasterCard/American Express/Discover). For accountsto stay in good standing, a payment must be made on it every 30 days. Every effort will be made to work with our patients on delinquent accounts, but if the account is in default it will be turned over to a collection company where you could be responsible for collection effort fees, including interest, attorney fees and court costs.
Southside Foot Clinic, PC promotes a doctor-patient relationship that is based on trust, focusing on patients as individuals. The Doctor’s and our outstanding support staff strive to be fair and courteous in all of our dealings.
The following policy has been established to help us serve you better. It is necessary for us to make appointments in order to see our patients as efficiently as possible. No-shows, reschedules and late cancellations cause problems that go beyond any financial impact to our practice. When an appointment is made or a surgery is scheduled, it takes an available time slot away from another patient in need of medical care. Not canceling an appointment or a scheduled surgery in a timely fashion is unfair to other patients, some of whom may be quite ill and may unnecessarily delay the delivery of health care. For these reasons we have developed the following No show/Reschedule/Late Cancellation policy.
Policy for No-show/Reschedule/Late Cancellations of Appointments
Policy for No-show/Reschedule/Late Cancellations of Surgeries
I acknowledge that I have read and understand this No show/Reschedule/Late cancellation policy. I further understand that after my 2nd No-show/Reschedule/Late cancellation, I could be dismissed as a patient from the practice.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI purposes that are permitted or required by law. It also describes your rights to access and control your protected health information (PHI). “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.
We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices. You may request a revised version by calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.
How this Practice Protects Your PHI:
You may contact our Privacy Officer: KIRK LEMOINE / WENDY WINCKELBACH, DPM
Contact Information: (317) 882-9303
This notice was published and becomes effective on: SEPTEMBER 23, 2013