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Endicott Podiatrist | Endicott Insurance Waiver | NY | Mario G. Silvestri, DPM |

Mario G. Silvestri DPM, PC

Podiatric Medicine & Surgery

1003 Monroe Street

Endicott, NY 13760

607-484-3668

Office Hours
Monday:8:00am - 5:00pm
Tuesday:8:00am - 5:00pm
Wednesday:8:00am - 4:30pm
Thursday:8:00am - 5:00pm
Friday:8:00am - 4:30pm


Insurance Waiver
 

I acknowledge and authorize MARIO G. SILVESTRI, DPM, to deliver, teach, administer or perform as necessary, the product and treatment prescribed by my physician.  I authorize MARIO G. SILVESTRI, DPM to submit a claim(s) for services to my insurer on my behalf and I authorize MARIO G. SILVESTRI, DPM to release any of my medical information required by my insurer to process the claim(s).  I understand that I am responsible for, and I agree to pay, any portion of the amount due for such services not pain by my insurance carrier when resulting from deductibles, co-pays, coinsurance or amount due as patient responsibility.

 

Patient or Guarantor Signature: _______________________________________

Relationship to Patient:______________________________________________

 

NO SHOW POLICY

In the event that you are unable to keep your appointment with this office, it is imperative that you call to cancel and/or reschedule your appointment.  Any patient that does not keep his/her appointment and has not called to cancel, will be charged a $25.00 FEE.  You will not be permitted to schedule an additional appointment until this fee is paid.  This policy is necessary to ensure that patients needing appointments can get them in a timely manner.  We thank you for yur cooperation with regard to the aforesaid.  Should you have any questions please contact the office manager.

 

Patient Signature:____________________________________________________

 
 
Endicott Podiatrist Mario G. Silvestri, DPM is a poidiatry office providing Insurance Waiver, orthopedic, pain, diabetes, bunions and much more in Endicott, NY. We also do Achilles Tendonitis, Allergic Contact Dermatitis , Athlete's Foot, Brachymetatarsia, Bunions, Calluses, Diabetic Foot Care, Flatfoot (Fallen Arches), Ganglions, Haglund's Deformity, Hallux Rigidus, Hammertoes, Heel Pain/Fasciitis, Infections, Injuries, Ingrown Toenails, Metatarsalgia, Morton's Neuroma, Onychomycosis, Osteoarthritis, Pediatric Foot Care, Plantar Warts, Plantar Fasciitis, Posterior Tibial Dysfunction, Rheumatoid Arthritis, Running Injuries, Sesamoiditis, Sprains/Strains, Tarsal Tunnel Syndrome, Taylor's Bunion, Tendonitis, Toe Deformities, Xerosis and all work related in the 13760 area and surrounding areas in Endicott
 

Mario G. Silvestri, Dpm