|
My signature
gives consent for Foot Soothers
Routine Foot Care services to be
administered to
____________________________________
. A
Resident
of________________________________________________________
(Assisted (Living Facility).
My signature gives
permission for an appropriate representative of Foot
Soothers to review the above residents medical record
including
prescription information.
I
give my permission for a photograph to be made of the
residents feet.
If a
resident is medically eligible, Foot Soothers will directly
bill
Medicare and/or my supplemental insurance for services
provided.
Any balance of fees will be billed to me or
anyone acting as my representative. I I understand that a
copy of the Medicare or other
insurers card will be made by
Foot Soothers and with my signature I give permission for
Foot Soothers to use this information for billing
purposes
only.
I understand if a resident is not medically
eligible for insurance reimbursement, I will be contacted to
arrange any future services
before they are provided.
* This form constitutes your "electronic signature", which
is a binding legal agreement. |
