Summary of Notice of Privacy Practices

Uses and Disclosures of Health Information. We will use and disclose your health information in order to treat you or to assist other health care providers in treating you. We will also use and disclose your health information in order to obtain payment for our services or to allow insurance companies to process insurance claims for services rendered to you by us or other health care providers. Finally, we may disclose your health information for certain limited operational activities such as quality assessment, licensing, accreditation, and training of students.

Uses and Disclosures Based on Your Authorization. Except as stated in detail in the Notice of Privacy Practices, we will not use or disclose your health information without your written authorization.

Uses and Disclosures Not Requiring Your Authorization. In the following circumstances, we may disclose your health information without your written authorization.

• To family members or close friends who are involved in your health care and are approved by you
• For purposes of public health and safety
• To government agencies for purposes of their audits, investigations, and other oversight activities
• To government authorities to prevent child abuse or domestic violence
• To the FDA to report product defects or incidents
• To law enforcements authorities to protect public safety or to assist in apprehending criminal offenders
• When required by court orders, search warrants, subpoenas, and as otherwise required by law.

Patient Rights. As our patients, you have the following rights:

• To have access to and/or a copy of your health information
• To receive an account of certain disclosures we have made of your health information
• To request restrictions as to how your health information is used or disclosed
• To request that we communicate with you in confidence
• To request that we amend your health information
• To receive notice of our privacy practices

If you have a question, concern, or complain regarding our privacy practices, please refer to the Notice of Privacy Practices for the person or persons whom you may contact.

I (we) hereby certify that the above information is correct to the best of my knowledge and give permission for Wasatch Foot & Ankle Institute or assistants to examine and treat my ailments medically, surgically, or orthopedically as the case may be.

I(we) also authorize the release of any information including the diagnosis and records of any treatments or examination rendered, to my insurance company or companies. This release is solely for the purpose of facilitating the billing and reimbursement, directly to the doctor, of insurance benefits under which I am entitled.

I(we) hereby authorize Wasatch Foot & Ankle Institute to (1) release any information necessary to insurance carriers regarding my illness and treatments; (2) process insurance claims generated during examination or treatment; and (3) allow a photocopy of my signature to be used to process insurance claims for the period of the policy lifetime. This order will remain in effect until revoked by me in writing.

I further understand that fees are due and payable on the date that services are rendered, and I agree to pay all such charges incurred in full immediately upon presentation of the appropriate statement.

Your insurance is a contract between you and your insurance company. We bill your insurance company as a courtesy to you. You are responsible for any unpaid balances. To file correct claims, you must provide ALL correct insurance information. Your bill is your responsibility whether your insurance company pays or not. You may need to contact your insurance company regarding payment. If your insurance company has not paid your account within 180, your account balance must be paid by you.

Other Office Policies

SELF-PAY: If you do not have insurance you are required to pay 100% of services rendered at time of service.

LATE POLICY: If you are more than 10 minutes late to your appointment, you will be asked to reschedule.

NO-SHOW: After three consecutive no-shows, you will be asked to pay a broken appointment fee of $25 in order to be scheduled again.

INSURANCE CARD: If you do not have your insurance card at appointment, you will be rescheduled.

Advance Beneficiary Notice of Non-covered (ABN)

NOTE: If your insurance doesn't pay for services below, you may have to pay.

Your insurance does not pay for everything, even some care that you or your healthcare provider have good reason to think you need. We expect your insurance may not pay for the services below.

Services:	Estimated Cost:	Reasons Insurance May Not Pay:
CAM Boot (L4360) Pantar Fas. Sleeve (L1902) Ankle Brace (L1906) Night Splint (L4396) Post-Op Shoe (L3260) Bunion Splint (L3100) Crutches (E0110) Custom Orthotics (L3000)	$100.00 $15.00 $50.00 $75.00 $25.00 $20.00 $40.00 $400.00	Your insurance company usually does not pay for this service. Your insurance does not usually pay for this many treatments or services. Your insurance does not pay for this because it is treatment that has yet to be proved effective (experimental)

WHAT YOU NEED TO DO NOW:

● Read this notice, so you can make an informed decision about your care.

● Ask us any questions that you may have after you finish reading.

● Choose an option below about whether to receive the services listed above.

Note (For Medicare): If you choose Option 1 or 2, we may help you to use any other insurance that you mighthave, but Medicare cannot require us to do this.

Additional Information

This notice gives our opinion, not an official insurance decision. If you have other questions on this notice or insurance billing, call the number on the back of your insurance card for more details. Signing below means that you have received and understand this notice. You also receive a copy.