Your personal details. Please review them and make any necessary adjustments.
PAYMENT AND INSURANCE INFORMATION
FOOT HEALTH HISTORY
SIGNATURE ON FILE AND PERMISSION TO TREAT
I understand that the informationprovided on this form is true and correct to the best of my knowledge.
I request that payments of authorized benefits be made on my behalh for any services furnished by Rainville Health.
I authorize any holder of information about me to released any information needed to determine these benefits or the benefits payable to related services to the insurance agent.
I recognize my financial obligationof any coinsurance, co-pay or deductible and non-covered services that may be required.
I hereby give permission to Rainville Health qualified staff to evaluate, diagnose and treat&edsp;&edsp;my foot related condition as may be deem necessary.
I attest that I am receiving treatment at Rainville Health because I want to get better.