Financial Agreement

American Board of Podiatric Surgery

Fellow, American College of Foot Surgeons

Stephen R. Pittman, D.P.M., PA.

410 Christiana Medical Center

Newark, Delaware 19702

Financial Agreement

The responsibilities whose signatures appear below agree as follows:

**The responsible parties agree to pay for all fees and supplies, services and treatment incurred by the patient.  If there is a fee for appliances/orthotics that is not covered by insurance, this is payable by the patient. A tray fee for any surgical procedure done in our office is subject to a fee payable by the patient. This is to cover our expense of sterilization and use of disposable materials not covered by the insurance company.

**The responsible party agrees to pay for all deductibles, co-payments, non-covered services, and any other portion of covered services not paid in full by the plan, and understands that such payments are due at the time of service, or immediately upon receipt of a bill for said services.  If payment is not received by the next billing cycle, it is subject to a monthly finance charge.

**If an account is referred to an outside agency for collection, the responsible party agrees to pay all costs related to such action.  An account will be referred to a collection service if no payment has been received within 90 days of service.

**Payment will not be delayed or withheld, regardless of lawsuits, liens, insurance coverage, and the dependency of claims or the outcome of medical treatment.  It is the responsible party’s obligation to assist the doctor in every way to submit payment to the extent their help is required.

**Patients who fail to keep appointments, or who cancel on short notice two or more times are subject to a $25.00 broken appointment fee.  The broken appointment fee is to be paid prior to being seen by Dr. Pittman and is non-refundable.

Accepted: I have rea the above financial policy and agree to payment as stated.

Signature___________________________________Date__________________Payment:  Cash, Check, Visa,

MasterCard, and Debit are accepted.

Medicare Patients

Podiatric service may not be considered to be medically necessary by Medicare and therefore may not be reimbursed as a covered expense.  It is the patient’s responsibility to pay for services rendered regardless of Medicare’s determination.  Podiatric services that may not be covered by Medicare are:

*Routine foot care (trimming nails, corns/calluses) is not a covered expense unless you are diabetic.

*The medical service may be performed longer or more often than Medicare allows.

*Patient’s deductible has not been met.