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The Foot and Ankle Group
I hearby authorize a physician of The Foot and Ankle Group to submit a claim to my insurance carrier or its inter-mediaries for all coverd services rendered by The Foot and Ankle Group and DIRECT MY INSURANCE CAR-RIER OR ITS INTERMEDIARIES TO ISSUE PAYMENT CHECK(S) DIRECTLY TO THE FOOT AND ANKLE GROUP for services I did not pay for. I understand I am financially responsible to The Foot And Ankle Group for any balance not covered by my insurance carrier. A copy of this signature is as valid as the original.
The Foot and Ankle Group
The Foot and Ankle Group
The Foot and Ankle Group
MedicationsThe Foot and Ankle Group
Medication Dose
The Foot and Ankle Group
90 days & over will be turned over to collections
Payments for services are due at the time service is rendered. We accept cash, checks and money orders. We also accept Visa, Mastercard and Discover. To assist you in making payments if special circumstances arise, we would be happy to arrange an automatic debit payment schedule to facilitate regular agreed upon payments.
