Financial Responsibility Disclaimers

1. The Foot Clinic will collect your deductible, co-pay, uncovered services, or coinsurance you are responsible for at the time of your visit. It is the patient’s responsibility to know the terms of their insurance plan. Please be prepared to pay copays and balances at the time of service. If you have not met your deductible, we will collect payment for the estimated amount allowed by your insurance plan or New Patient visits are $100; Follow up visits are $50.
2. If your insurance denies payment on your account, you will be asked to pay by check, cash, or charge.
3. You may receive statements or notifications via text message and/or e-mail.
4. TERTIARY: The Foot Clinic will submit claims to primary and secondary insurances only. It is your responsibility to provide your third insurance with a billing statement of any remaining unpaid charges. Please be aware that any amount remaining AFTER insurance processes a claim is your financial responsibility.
5. NO SHOW POLICY: See below.
6. COLLECTIONS: Should your account become delinquent and over 90 days old, you will need to contact our billing department to establish a payment arrangement before making another appointment.
7. RETURNED CHECKS: There is a $40 charge for returned checks or declined credit card charges from mailed in payments.
8. SELF-PAY PATIENTS: This category includes patients with no insurance and the patients who have an insurance plan with which we do not participate or an insurance plan that does not provide podiatry benefits. Payment for medical services is required prior to services being rendered. We accept Visa, MasterCard, Discover and American Express, checks, cash, and money  orders.
9. PRIOR AUTHORIZATION: The Foot Clinic does not provide Prior Authorization services. We apologize for the inconvenience.
10. An administrative collection fee of 28% will be added to all accounts over 90 days past due.

By signing below, I acknowledge I have read these disclaimers.