Financial Responsibility
All professional services rendered are charged to the patient and are due at the time of service, unless other arrangements have been made in advance with our business office. Necessary forms will be completed to file for insurance carrier payments.
Assignment of Benefits
I hereby assign all medical and surgical benefits, including major medical benefits to which I am entitled. I hereby authorize and direct my insurance carrier(s), including Medicare, private insurance, and any other health/medical plan, to issue payment check(s) for medical services rendered to myself and/or my dependents regardless of my insurance benefits, if any, directly to the following practice name and address:
Name: Western PodMed Clinic, Inc., A Podiatric Corporation
Billing Address: PO Box 19399, Belfast, ME 04915-4088
Furthermore, I understand that I am responsible for any amount not covered by insurance.
Authorization to Release Information
I hereby authorize Western PodMed Clinic, Inc., A Podiatric Corporation to:
- Release any information necessary to insurance carriers regarding my illness and treatments;
- Process insurance claims generated in the course of examination or treatment; and
- Allow a photocopy of my signature to be used to process insurance claims for the period of a lifetime.
This order will remain in effect until revoked by me in writing.
I have requested medical services from Western PodMed Clinic, Inc., A Podiatric Corporation on behalf of myself and/or my dependents, and understand that by making this request, I become fully financially responsible for any and all charges incurred in the course of the treatment authorized.
I further understand that fees are due and payable on the date that services are rendered and agree to pay all such charges incurred in full immediately upon presentation of the appropriate statement. A photocopy of this assignment is to be considered as valid as the original.
OPEN PAYMENT DISCLOSURE (Effective 01/01/2023)
The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov
I have read and agreed to all statements, terms, and conditions above.