I, , understand that I am being seen for podiatric issues. The care is known to be effective only when provided on a regular basis. Lapses in my treatment, such as missed days or sporadic days, or failure to comply with the plan of care can result in this therapy becoming less effective, ineffective or made worse. I understand that, without my active participation, my doctor’s ability to help me is limited. My responsibilities include but are not limited to:

1. Learning how to promote my own health and wellness. Being an active partner in my medical care/healing.
2. Learning how to manage illness, both acute and chronic.
3. Actively working to eliminate those unhealthy habits I have acquired over my lifetime.
4. Eating properly, exercising if indicated, and striving to eliminate those stressors within my control.
5. Understanding my diagnosis, learning about its effects on my body and how I can help manage it.
6. Understanding the medical advice I receive. Asking questions when I do not understand the advice offered.
7. Taking my medications as prescribed if prescribed.
8. Notifying On 2 Feet, LLC prior to stopping or changing dressing treatment or my medication.
9. Notifying On 2 Feet, LLC should I have any adverse reaction from my prescribed treatment.
10. Completing diagnostic tests (lab, x-ray, EKG, etc.) in a timely fashion.
11. Appearing for treatment as scheduled. If I am unable to appear for a scheduled appointment, I will notify On 2 Feet, LLC, and also make every arrangement possible to reschedule for that same day during regular business hours.
12. That I will not miss any more than one (1) day of treatment in the entire recommended treatment plan.
13. Notifying my doctor when I have added other professionals to my healthcare team.
14. Notifying On 2 Feet, LLC if other professionals have prescribed new medication and what that medication is, and why it is being prescribed.
15. Being honest about what I am doing, taking, and who I am getting treatment from.
16. Know the rules of my insurance policy, which benefits are covered and which are not.
17. Notifying the office if any contact or coverage information changes occurred.
18. Having an emergency contact listed should critical information needs to be relayed.
19. I understand that a violation of any of these conditions may result in my discharge from On 2 Feet, LLC care.

My health is important to me, my family, and loved ones. I will work hard to care for myself. I understand that my doctor cannot help me if I will not help myself. I expect my doctor to offer me his/her best advice based on his/her medical training.

Appointments

Office visits are by appointment only, please call (407) 391-3344. The receptionist may ask about the reason for your visit. This helps us schedule the doctor’s time more efficiently. Please arrive 10 minutes early for your appointment. Patients who are late for an appointment may be asked to reschedule at the physician’s discretion. Remember, it is your responsibility to update staff of any changes to your address, phone number, insurances, medications or any new specialist or primary physician treating you. We know that your time is valuable. Except in the case of emergencies, you can expect us to be running on schedule.

Cancellation

We would like to thank you for being a patient in our office. We value ALL of our patients and strive to provide the best podiatric care possible in the most comfortable setting. Please understand that when we schedule your appointment, we are reserving time for your particular needs – a room is reserved, records are prepared, and special instruments are readied for your visit. We kindly ask that if you must change an appointment, please give us at least 24 hours advance notice. This courtesy makes it possible to give your reserved time to another patient who is in need.

Missed Appointment (non-cancellation)

We understand that occasional missed appointments can occur for a variety of reasons. When you miss an appointment without canceling, someone else who could have been seen in your place is delayed, unnecessarily. We track missed (non-canceled) appointments. A “No Show / Late Cancellation” is defined as missing an appointment without canceling at least 24 hours before the scheduled time. There will be a charge for missed or non-canceled appointments of $50.00. Insurance will not cover charges for no show/late cancellation. The $50.00 charge is in addition to any other charges you may have incurred. No refunds will be given. Repeated missed appointments may result in your physician sending a letter discharging you from the practice. We will offer to transfer your medical records to your new podiatrist, meanwhile, we will offer 30 days of emergency care only.

Payment

Payment is due when you call us to reschedule an appointment or at the time of the visit.

On 2 Feet, LLC’s Notice of Privacy Practices provides information about how we may use and disclose protected health information (PHI) about you. You have the right to review this notice before signing. As outlined, the terms of the notice may change, and you may obtain a revised copy by contacting On 2 Feet, LLC.

You have the right to request restrictions on how your PHI is used or disclosed for treatment, payment, or health care operations. While we are not required to agree to restrictions, if we do, we are bound by them. By signing this form, you consent to the use and disclosure of your PHI for treatment, payment, and health care operations as described in the notice. You may revoke this consent in writing, except when reliance has already occurred.

Voice Recordings and AI Authorization:

On 2 Feet may use voice recordings for the purpose of creating, maintaining, and enhancing medical documentation related to my care. I understand that these recordings may be processed by artificial intelligence (AI) systems to assist with accurate and efficient documentation. All voice data and corresponding documentation will be handled in accordance with privacy laws, including HIPAA. I have the right to revoke this authorization in writing without affecting my medical care.

Image Consent:

I consent to photographs, videotapes, digital, or other images being recorded to document my care. I understand that Dr. Mennuti retains ownership of these images, but I may view or request copies. These images will be securely stored and used only with written authorization, unless required by law or policy.

Authorization for Messages and Automated Calls:

I give On 2 Feet, LLC permission to contact me by phone (including wireless) at the numbers I provide, including through automated or pre-recorded messages, and via email or text. These communications may include legally required information or messages about my continued care. I understand that debt collection agencies may also contact me via these methods. If I wish to limit communications to specific numbers, I must designate them.

Your understanding of our financial policies is an essential element of your care and treatment. If you have any questions, please discuss them with our front office staff or supervisor.

As our patient, you are responsible for all authorizations/referrals needed to seek treatment in this office. Unless other arrangements have been made in advance by you, or your health insurance carrier, payment for office services are due at the time of service. We will accept VISA, MasterCard, Discover, cash or check. Please note that if you choose to pay with a credit card, a processing fee may be added to your total bill. Refunds, if issued, do not include any fees incurred.

Your insurance policy is a contract between you and your insurance company. As a courtesy, we will file your insurance claim for you if you assign the benefits to the doctor. In other words, you agree to have your insurance company pay the doctor directly. If your insurance company does not pay the practice within a reasonable period, we will have to look to you for payment.

We have made prior arrangements with certain insurers and other health plans to accept an assignment of benefits. We will bill those plans with which we have an agreement and will only require you to pay the co-pay/co-insurance/deductible.

If you have insurance coverage with a plan with which we do not have a prior agreement, we will prepare and send the claim for you on an unassigned basis. This means your insurer will send the payment directly to you. Therefore, all charges for your care and treatment are due at the time of service. All health plans are not the same and do not cover the same services. In the event your health plan determines a service to be “not covered,” or you do not have an authorization, you will be responsible for the complete charge. We will attempt to verify benefits for some specialized services or referrals; however, you remain responsible for charges to any service rendered. Patients are encouraged to contact their plans for clarification of benefits prior to services rendered.

You must inform the office of all-insurance changes and authorization/referral requirements. In the event the office is not informed, you will be responsible for any charges denied.

For most services provided in the hospital, we will bill your health plan. Any balance due is your responsibility.

There are certain elective surgical procedures for which we require prepayment. You will be informed in advance if your procedure is one of those. In that event, payment will be due one week prior to the surgery.

Past due accounts are subject to collection proceedings. All costs incurred including, but not limited to, collection fees, attorney fees, and court fees shall be your responsibility in addition to the balance due to this office. There is a service fee of $50.00 for all returned checks. Your insurance company does not cover this fee.

Florida law (Section 817.5655, Florida Statutes) prohibits the sale or transfer of a person’s biological specimen from which DNA can be extracted to a third party without the express consent of such person.

During the course of your care at ON 2 FEET, it may be medically necessary to obtain a blood, urine, stool, tissue or other type of biological specimen for analysis. This analysis will not involve the examination of your DNA to identify the presence and composition of genes in your body. After the analysis has been performed and the sample is no longer needed, it will be stored as medical waste and then transferred to a third party for disposal in accordance with all local, state and federal requirements.

It may also be the case that a biological specimen (such as blood, urine, hair, bodily fluids, etc.) from you may be deposited on medical instruments, bedding, clothing or other objects. These objects may then be transferred to a third party for cleaning or disposal.

By signing this document, you affirmatively state that it is your intentional decision to consent to the transfer of any and all biological specimens collected by or deposited with ON 2 FEET to a third party as set forth above. This consent does not authorize the sale or transfer of a biological specimen for the purpose of DNA analysis.