Thank you for choosing our office for your podiatric healthcare. We are committed to a successful treatment of your medical needs and make you, the patient, our first and foremost concern. As part of our service we try to contain the cost of healthcare and in an effort to do this, we have implemented a financial policy.

• If we are a participating provider with your insurance plan we will submit the claim to your insurance company for you. To do this we must have complete and accurate insurance information and a copy of your identification card or claim form. Your insurance policy is a contract between you and your insurance company; therefore you are responsible for payment whether or not your insurance company pays. It is your responsibility to contact your insurance company regarding pre-certifications, required referrals, authorizations, etc. Failure to do so may reduce the amount of benefits paid by your insurance policy and balance will then become your responsibility to pay. All co-payments must be paid at the time of service.
• If you do not have insurance or the doctor is not a participating provider with your insurance plan, please be prepared to fully cover the fees for each visit at the time of treatment.
• Payments for the balance due, co-payments, deductibles, etc. are due at the time of service and may be made by cash, check or credit card. There will be a $25 charge for returned checks. Delinquent accounts will be referred for collection at the discretion of the office manager.
• Please be prepared to pay all co-payments at the time of service. We do not send bills out for co-payments, so your visit will have to be rescheduled if you are not prepared to pay the co-payment.
• If you have an annual deductible which has not yet been paid in full, then any charges incurred up to that amount are due at the time of your visit.
• The adult or the parent (custodial guardian) accompanying a minor is responsible for payment of services. For unaccompanied minors, non-emergency treatment will be denied unless prior authorization from the parent or guardian has been made for the charges and treatment. Young adults (age 18 and over) are legally responsible for their accounts unless a parent accompanies them to the initial appointment and signs this financial agreement, regardless of insurance coverage.
• Orthotics are a non-covered service by some insurance plans. Please check with your insurance company prior to the examination and casting for orthotics to determine your orthotic benefits. A deposit of $100 is requested at the time of the examination and casting. Full payment is due when the orthotics are dispensed.
• For your convenience we make some supplies available for purchase in the office. If you choose to purchase these items, payment is due at the time of purchase. We cannot bill for these items.

I the undersigned certify that I (or my dependent) have insurance coverage with the above listed agents and assign directly to Quad Cities Foot & Ankle Associates, P.C. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for any charges whether or not paid by insurance. I hereby authorize the use of this signature on all insurance submissions.

I acknowledge that I was provided 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.