New Patient Forms

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FINANCIAL POLICY
Thank you for choosing FAMILY FOOT HEALTH, Dr. Howard Burkett for your foot care. The following is a statement of our financial policy, which we ask that you read and sign prior to any treatment.
INSURANCE
Your insurance policy is a contract between you and your insurance carrier. We will submit the medical services provided to your insurance carrier if you have provided all of the required information. We must have the current policy number; group I.D. number; billing address and required referral if necessary. Please understand that you may have restrictions imposed by your insurance carrier on services that may or may not be covered by your insurance as well as co-pays and deductibles. Payment is required at the time of service for any charges that may not be covered by your insurance. Co-pays and deductibles as well as any prior balance is required at the time of service. A CHARGE MAY BE MADE IF WE ARE REQUIRED TO BILL FOR A CO-PAYMENT OR HAVE TO BILL MORE THAN ONCE FOR A PERSONAL BALANCE. Patients who choose to be evaluated outside of their insurance provider network will be expected to pay all fees in full and submit the charges to their insurance carrier.
OUR BILLING PROCESS
All co-pays are due at the time of your visit. Our office will file and insurance claim within 2-5 days of your visit. If our office does not receive a response from your insurance carrier within 60 days you will be billed for services rendered. A billing statement covering the medical services will be mailed to you on a monthly basis. Personal balances over 30 days past due will be subject to an additional billing charge of $8.00. After 90 from the original date of service, our office will place all delinquent accounts with the Cumberland County District Magistrate for collection proceedings. You will be responsible for all collections fees and court for all delinquent accounts 90 days past due. Our office will accept VISA; Mastercard; personal check and cash for payment. A $30.00 returned check fee will be charged for any check that is returned from your bank.
MINOR PATIENTS (UNDER AGE 18)
The parent/guardian/adult accompanying the minor child is responsible for payment. We must have pre-approval from a parent or legal guardian for any treatment rendered to a minor. Any patient over the age of 18, is a legal adult and will be treated as such with regard to any financial obligation. In a divorce case, the parent who brings the child into our office for medical services is ultimately the responsible party. I have read the above financial policy and I fully understand my legal responsibility as a patient/parent or legal guardian.
Date
MM slash DD slash YYYY
Relationship
Name
First Last
Signature

Patient Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Drivers License Number
Phone Number
Employer
Employer Phone
Occupation
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Name of Insurance Plan
I.D.#
Group #
Insurance Phone
Insurance Address
Street Address Address Line 2 City State ZIP Code
Marital Status*
Spouse's Name
First Last
Spouse Date of Birth
MM slash DD slash YYYY
Emergency Contact Name
First Last
Emergency Contact Phone
Responsible Party if a Minor
First Last
How Did You Hear About Us
Family Physician
First Last
Pharmacy
Phone
Person Financially Responsible for this Account
First Last