Foot Health and Wellness


Financial Responsibility

I understand that I am ultimately responsible for payment of expenses rendered on my behalf or for those under my guardianship whether or not I have insurance coverage or not. It is my responsibility to determine if I have a valid referral for services provided, and if this service is covered by my insurance. I also realize I am responsible to pay my Copay and/or deductible at the time of service. In addition, I am required to pay any balances or fees for service not covered by my insurance provider.

In divorce/custody situations, the person with the full time legal custody is ultimately responsible for the payment of our services even if the insurance is provided by the other parent or guardian. In 50/50 custody, we bill the parent where the child resides for school purposes. If the other parent has insurance responsibilities, we need that parent’s legal authorization in writing, including legal signature, billing and insurance information.

Unpaid balances over 90 days may be referred to an outside collection service unless payment arrangements have been made with our accounting staff. A $35.00 charge will be made for all returned checks. A $3.00 Rebilling Fee will be charged each month on accounts over 90 days.

No Insurance

If you have no insurance, payment is required at the time of service, unless payment arrangements are made with our staff.

Missed Appointments

We require 24 hour notice to change or cancel appointment to avoid a $35.00 fee.



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