- I understand and agree that I am responsible for the balance of my account for any professional services rendered, regardless of my status or insurance coverage.
- I understand that if required, I am responsible for obtaining a referral from my primary care physician, even if I was first seen in the hospital/emergency room.
- I understand and agree that if I do not have health insurance or a current referral, a $100.00 deposit is required at the time of my visit and a payment plan will be set up to pay the remainder of the cost.
- I understand that my co-payment is to be paid at the time of my visit.
- I understand that $50.00 will be charged for each appointment missed without providing prior notice to Dr. Marilyn Boyuka, and there will be a $36.00 charge for bounced/insufficient funds checks written.
- I authorize the use of this form on all insurance submissions. I authorize Southern Tier Podiatry to act as my agent in helping me obtain payment from my insurance company and I authorize payment of medical benefits directly to Southern Tier Podiatry. I authorize Southern Tier Podiatry to release medical information required to process my claim.
- Insurance Deductible Policy: If your deductible has not been met at the time of your appointment, we will collect 60% of the charges for that day of service, at time of your visit. Your insurance company will be billed and if you owe an additional amount; you will receive a balance bill.
To view the full Office Policy please click here.
