Foot Health and Wellness



Assignment of Benefits

Your signature is necessary for us to process your insurance claim, and to insure payment of benefits for services rendered on your behalf.

I hereby authorize any payment of insurance benefits for Podiatry services rendered by Robert W. Geister, DPM, on my behalf, to be made directly to Dr. Geister. I authorize any holder of medical information about me to release to the insurance carrier, or to Health Care Financing Administration and its agents, any information needed to determine benefits payable for related services provided by Dr. Geister. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as the original.


HMO Referrals

It is my responsibility to know whether a referral is required for payment of services rendered by Dr. Geister. It is my responsibility to obtain the appropriate referral from my primary care physician. In some cases a specific referral needs to be obtained for X-Ray or surgical services. If a written referral has not been received by Dr. Geister’s office at the time of my visit then I may be financially liable for payment for the services provided, and I hereby agree to be responsible for payment of these services.

I also realize that even with a valid physician referral that some services may not be covered by my insurance provider, (such as routine foot care), and I agree to pay for these services if they are not covered.


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