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Please confirm an appointment with our office before filling out this form
I. Dr. Angermeier/Dr. Hensley has my permission to treat my (the Patient’s) foot problem. II. In accordance with the Notice of Privacy Practices, I authorize Dr. Angermeier/Dr. Hensley to disclose my medical records as necessary to obtain payment from my insurance company or other third-party payer. I authorize the payment of medical benefits to Richmond Foot & Ankle Surgical Associates. I accept financial responsibility for any claim denied for want of a referral. III. Routine Foot Care: Health insurance plans generally do not cover foot care such as cutting toenails or trimming calluses. In the case my insurance denies any service, I accept financial responsibility for non-covered foot care as recommended by my podiatrist.
I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
Conduct, plan, and direct my treatment and follow-up care among multiple healthcare providers who may be involved in that treatment directly and indirectly;
Obtain payment from third-party payers;
Conduct normal healthcare operations such as quality assessments and physician certifications.
I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of Privacy Practices.
I understand that I may request in writing that you restrict how my private information is disclosed to carry out treatment, payment, or other health care operations. I also understand you are not required to agree to my requested restrictions, but that if you do agree, then you are bound to abide by such restrictions.
I understand that I may revoke this consent in writing at any time except to the extent that you have taken action relying on this consent.
So that Dr. Angermeier/Dr. Hensley may better provide podiatric care, I authorize him/her to communicate with my other healthcare providers or my insurance carrier to obtain my recent medication history. Such history may include details about the name, strength, dosage, dispensing, available refills, and reaction to any prescription medication I have been given within the past twenty-four months. This information shall be used only for my care, to coordinate with my other healthcare providers, or to fulfill requirements of the law.
IF I DECLINE to give Dr. Angermeier/Dr. Hensley this authorization, I understand that I may be limiting my treatment options or may be exposing myself to a higher risk of such adverse drug interactions as overmedication, stroke, seizures, or organ damage. I also understand that Dr. Angermeier/Dr. Hensley is authorized by law to use the resources of the Virginia Prescription Monitoring Program to prevent the abuse or diversion of controlled substances.
To provide for better medical treatment and to reduce duplicate services, I authorize any of my physicians or other healthcare providers to send Dr. Angermeier/Dr. Hensley medical records or the results of any medical test from the previous twenty-four months which may be appropriate for my podiatric care. Some examples of such tests would be radiology reports, neurology reports, blood or urine analyses, allergy tests, tissue pathologies, or culture tests for infection. These examples are not exhaustive. I authorize my physicians or other healthcare providers to use their medical judgment or to consult with Dr. Angermeier/Dr. Hensley about the propriety of sending such information.
I likewise authorize Dr. Angermeier/Dr. Hensley to send to my physicians or other healthcare providers medical records or the results of any medical test he may perform which may be appropriate for my medical care.
Unless urgently necessary for my welfare, such highly personal information as my mental or behavioral health should not be sent without my specific consent. My providers may, however, review my podiatric care with Dr. Angermeier/Dr. Hensley and note potential complications or contraindications.
Late / No Show Policy
In an effort to provide the best care for all of our patients, we have implemented new policies regarding late arrivals and no shows. If you are unable to make your scheduled appointment, please notify the office at least 24 hours before your scheduled appointment. We understand that things happen, but please let us know as soon as possible. If you arrive more than 10 minutes late for your appointment, you will be asked to reschedule depending on appointment availability that day or may incur a wait if the physician has openings in their schedule.
For No Shows and last-minute cancellations (less than 24-hour notice), a $50 dollar no show fee/cancellation may be added to your account, which must be paid in full before you can be seen in the office again. This fee will be applied again for all subsequent no shows as well. After the third no show, we reserve the right to discontinue services and care.
Outstanding Balances
Any balances that are 30 days or more overdue must be paid in full before you can be seen by the doctors in the office. Any balances that are 30 days or longer overdue are subject to being sent to a collection agency. If your account is sent to a collection agency, we reserve the right to discontinue services and care.
By signing this form below, I have reviewed and understand the late/no show and the outstanding balances policies outlined above
