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

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Mario G. Silvestri DPM, PC

Podiatric Medicine & Surgery

1003 Monroe Street

Endicott, NY 13760

607-484-3668


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:____________________________________________________


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Please do not submit any Protected Health Information (PHI).