South Scottsdale Office: (602) 955-3338 Mesa Office: (480) 833-5966 North Scottsdale Office: (480) 483-9000 Sun City Office: (623) 977-8388
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Please complete the following form and answer all questions before arriving for your appointment.
Be sure to include your insurance information.We'll see you soon!
*This information is requested due to Healthcare Reform laws dictated by Congress.
Which family members had the below medical conditions? (father, mother, sibling, etc.)
Assignment and Release I certify that I, and or my dependent(s) have insurance coverage and assign all benefits directly to the office of Arcadia Foot and Ankle. I understand I will be responsible for any portion of the claim, which is denied or not covered by my insurance company. I authorize the release to my insurance carriers any information necessary to process this claim.
ACKNOWLEDGEMENT OF REVIEW OF NOTICE OF PRIVACY PRACTICES: I have received a copy of the Privacy Policy from this provider and authorized the above list of persons who may receive my Protected Health Information. I may revoke this at any time by giving written notification to this provider. Arcadia Foot and Ankle participates in an organized health care arrangement consisting of the greater Phoenix metropolitan area hospitals as well as physicians who have medical staff privileges at one or more of these hospitals. Participants in this arrangement work together to improve the quality and efficiency of the delivery of health care to their patients. As a participant in this arrangement, we may share your PHI with other members of this arrangement for purposes of treatment, payment or health care operations of this organized health care arrangement.
I HEREBY AUTHORIZE MY INSURANCE COMPANY TO MAKE PAYMENTS DIRECTLY TO: Arcadia Foot and Ankle
I understand that I am financially responsible for any co-payments, deductibles, co-insurance, and all charges, which are not covered by my insurance. I understand that there will be a $25.00 service charge on all returned checks. I understand that verification of benefits is not a guarantee of payment. (Insurance benefits are determined by your insurance company when the claim is received.) I understand that I will be responsible for any portion of the claim that is allowed by, but not covered by, my insurance company.
Delinquent accounts will be turned over to a collection agency without notice. Accounts will be considered delinquent if unpaid after 60 days. In the event my account is turned over for collection, I will pay all reasonable collection, court and attorney costs at the time the account is considered delinquent.
APPOINTMENT NO SHOW POLICY: I understand that I am responsible for any missed appointments without 24 hour notification and will be responsible for a charge of $75.00.
RELEASE AND REQUEST OF INFORMATION: I hereby authorize Arcadia Foot & Ankle to release or request any medical information or incidental information by my referring physician or any other physician who have been or may become involved in my care.
Our physicians are bilingual in English, Spanish, and Portuguese
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