and assign directly to Littleton Foot and Ankle Clinic, PLLC all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. Littleton Foot and Ankle Clinic may use my health care information and disclose such information to the above named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below. I request that payment authorized Medicare/Medicaid/Private insurance benefits, and, if applicable, Medigap benefits be made either to me or on my behalf Littleton Foot and Ankle Clinic for any services rendered to me by that provider. To the extent of the law, I authorize any holder of medical or other information about me to release to the Center for Medicare and Medicaid services, my Medigap insurer, and their agents any information needed to determine these benefits or benefits for related services. I authorize Littleton foot and ankle clinic to contact the guarantor for billing questions only, no medical information will be disclosed. Non- covered Services Please be aware that some of the services you receive may be non-covered by your insurance carrier. These services must be paid for at the time of visit. There will be a $25-$50 charge for all paperwork needed to be filled out for work (FMLA), attorneys, etc. Claims Submission We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request promptly. The office will perform reasonable effort to notify you of services that may be denied or non-covered. The patient is responsible for any charges/services that the insurance company denies Payment For your convenience, we accept cash, checks, VISA, MasterCard, and Discover. We reserve the right to refer your account to a collection agency if your account is over 60 days past due. Any collection fees, court costs, reasonable attorney fees, or returned check fees are the responsibility of the adult person(s) named on the delinquent account. A collection fee is 20% of the amount due. Monthly service fee of 1.5% per month or 18% per annum will be assessed on all past due accounts.