Intake Form

I hereby authorize treatment by We Heel The Sole Podiatry, LLC. I understand that my healthcare information is private and that my insurance carrier will require this information in order to process claims for payment of services rendered by this medical provider. I authorize the release of pertinent medical information to my insurance carrier(s). I also authorize payments to be made directly to this medical provider by my insurance carrier(s).

I hereby give my consent for We Heel the Sole Podiatry, LLC to use and disdose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). (The Notice of Privacy Practices provided by We Heel the Sole Podiatry, LLC describes such uses and disclosures more completely.}

Irequest that payment of authorized Medicare benefits and, if applicable, Medicaid benefits, be made either to me or on my behalf to We Heel the Sole Podiatry, LLC for any services furnished to me by that provider. To the extent permitted by law, I authorize any holder of medical or other information about me to release to the Centers for Medicare and Medicaid Services, and their agents any information needed to determine these benefits or benefits related services.

Signing this form, I voluntarily give permission to Dr Jerwana Laster to provide Pediatric Medicine Care for the above patient This will include all treatment necessary for the care of the problem
associated with the diagnosis found.