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 use of this signature for all insurance claims (including Medicare/Medicaid if applicable).
I understand that there is a $25 fees for no shows, cancellation/rescheduling done later than 24 hours prior to the appointment time.
I agree that any balance less than 50$ will be directly taken out from the credit card saved to my account.
I agree that any balance over 50$ will be charged a 5% interest if not paid within 30 days.