PATIENT INFORMATION FORM

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.

Your understanding of our financial policies is an essential element of your care and treatment. If you have any questions, please discuss them with our front office staff or manager.

• Payment for services and/or devices are due at the time of service. We will accept VISA, MasterCard, American Express, debit or cash. Personal cheques are not accepted.
• Payment for visit fee(s), new or follow-up, are non-refundable. USED medical devices, like splints or braces, cannot be returned for refund unless the product is deemed defective, in which a replacement device may be issued.
• There are certain elective procedures for which we require pre-payment. You will be informed in advance if your procedure is one of those.
• We require a minimum of 24hrs notice if you need to cancel your appointment. Any appointment missed without a 24hrs cancellation notice will require all future appointment fees to be paid in advance as a deposit. Upon attending the next appointment an invoice for the appointment fee will be provided that may be submitted to extended insurance for reimbursement in the usual fashion. Missing this appointment without at least 24hrs notice will incur loss of the deposit paid and be applied as a no show cancellation fee for the missed appointment.

MSP of BC/ Premium Assistance Subsidies

• Podiatry is NOT a covered service of Medical Services Plan of BC. Our posted fees for services and procedures are exclusive of any MSP reimbursement and are your responsibility to pay.
• Patients who have MSP Premium Assistance may have a subsidy towards appointment fees. MSP will be billed directly by the practitioner for any applicable services or procedures. Any MSP reimbursements will be paid directly to the provider, either Dr. R. Stanford #60155 or Dr. S. Sandhar #J8607 at Aurora Foot & Ankle Clinic. You will not be charged for the subsidized portion that is reimbursable by MSP.

Private/Extended Medical Insurance

• We DO NOT have direct billing access to private medical insurance providers. Therefore, all charges for your care and treatment are due at the time of service. At the time of payment, we provide a receipt which may be used for submission to private insurance. Our rates are the same regardless of insurance coverage or lack thereof. If your extended insurer requires so, you are responsible for all authorizations/referrals needed to seek treatment in this office.

APPOINTMENT CONSENT
I understand that my appointment may include a physical foot exam, review of medical records and provision of services by either the podiatrists or footcare nurse at this facility, and that my medical records may be shared within the medical staff for purposes of collective podiatric services.