Patient Registration Form

Manhattan Podiatry Associates, PC
The below information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am
financially responsible for any balance. I also authorize Manhattan Podiatry or insurance company to release any information required to process my
claims. I acknowledge that I was provided and read (or had the opportunity to read)and understood The Notice of Privacy Practice
am aware that the following information is available for viewing upon request;
o Information regarding the providers of care in this organization
. A copy of the Patient's Bill of Rights and Responsibilities
. Information regarding the grievance process
. Ownership of Practice
. DNR Policy
. JCAHO lnformation
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