CONSENT TO TREATMENT

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICE
I acknowledge that I was provided a copy of the Prestige Ankle & Foot Care, LLC Notice of Privacy Practices which explains how my medical information will be used and disclosed. I have read (or had the opportunity to read if I so chose) and understand the Notice.

ACKNOWLEDGMENT OF RECEIPT OF FINANCIAL POLICY
I acknowledge that I was provided a copy of the Prestige Ankle & Foot Care, LLC’s Financial Policy. I have read (or had the opportunity to read if I so chose) the document and understand it and will comply by the policies stated.

AUTHORIZATION REGARDING PRIVACY POLICY
In accordance of the Health Insurance Portability and Accountability Act (HIPPA), I hereby authorize Prestige Ankle & Foot Care, LLC to leave messages at my home with family members and/or answering machines regarding the following: (1) Confirm or Change Appointment, (2) Status of referrals to any ancillary services or other specialties, (3) Any pertinent information that may be relative to my care.

CONSENT TO VIEW EXTERNAL/NARCOTIC PRESCRIPTION HISTORY
I authorize Prestige Ankle & Foot Care, LLC to view my external and/or narcotic prescription history via electronic prescribing services and/or the Georgia Prescription Monitoring Program. I understand that prescription histories from multiple other unaffiliated medical providers, insurance companies, pharmacies, and pharmacy benefit managers may be viewable by my provider and the staff at Prestige Ankle & Foot Care, LLC and they may include prescriptions from several years ago.

PATIENT CONSENT
I hereby voluntarily consent to outpatient care by a Prestige Ankle & Foot Care, LLC’s podiatrist encompassing routine care, diagnostic procedures. Examination and medical treatment that includes, but may not be limited to, minor surgical procedures, laboratory work, x-rays, ultrasound, photography, and administration of medications and injections prescribed by a Prestige Ankle & Foot Care, LLC’s podiatrist. I agree to ask questions to clarify treatment should I not understand the treatment plan.

INSURANCE ASSIGNMENT AND RELEASE
I certify that I have insurance with the insurance company(ies) disclosed and assign directly to Prestige Ankle & Foot Care, LLC and its podiatrists, all insurance benefits, if any, otherwise payable to me for service(s) rendered. I understand that I am financially responsible for all charges whether or not paid by my insurance.

Prestige Ankle & Foot Care, LLC may use my health care information and may disclose such information to the disclosed insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.

I have read and fully understand this Consent to Treatment. I have been given the opportunity to ask all questions regarding this document and find the answers provided satisfactory for me. This authorization is valid as of the date I have signed below and will remain in effect as long as I am a Prestige Ankle & Foot Care, LLC’s patient. I have read this complete page and agree to all of its contents.