I give permission to Moody Mankerious, DPM to examine/treat me during the care of my condition. I understand that I am financially responsible for all charges, whether or not paid by insurance. The only limitation to my financial liability for charges not paid by insurance occurs in the event of contractual limitations to the charged fees that have been agreed upon by Moody Mankerious, DPM and the insurance company. I authorize the use of this signature for all insurance claims (including Medicare/Medicaid if applicable)
I acknowledge that the above is true to the best of my knowledge. 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 as I chose) and understand the notice.
- I agree to have my debit or credit card information securely saved on file to pay my estimated copay or coinsurance on the day of each visit. I will be informed of the cost prior to usage.
- FMLA and Disability paperwork have a $25.00 fee for completion.
- I understand that if my balance hasn’t been paid after 90 days, it will be sent to collections.
- I understand that there is a $25 fee for no shows or any cancellation/rescheduling done later than 24 hours prior to the appointment time. It will be directly taken out from the debit/credit card saved to my account.