Podiatric Surgical Specialists

15760 19 Mile RS Suite E
Clinton Twp, MI 48038
*We are closed daily from 12:00pm-1:00pm


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I hereby authorize payment directly to Brian G Lader DPM PLC/or all insurance benefits otherwise payable to me for service rendered. I understand that I am financially responsible for all charges, whether or not paid by insurances, and for all services rendered on my behalf or my dependents. I authorize any provider and/or supplier of service in this office to release any information required in securing the payment of benefits. I authorize the use of this signatu re on all insurance submissions. I unde rstand I will be subjected to a $25 service fee if my check is returned unpaid. By signing this document , I agree, in order for Brian G Loder, DPM, PLC, to service my account or to collect any amounts I may owe, Brian G Loder, DPM, PLC, and its third party billing and/or debt collection service providers may contact me by telephone at any telephone number associated with my account, including wireless telephone numbers, which may result in charges to me. Addit ionally, I authorize contact via text messages or e-mails, using any e-mail address I provide. Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automatic dialing device, if applicable. I/We have read this disclosure and authorize express consent that Brian G Loder, DPM, PLC, its affiliates, and third party service providers may contact me/us as described above.

Brian G Loder DPM, PLC will use and disclose your personal health information to treat you, to receive payment for the care we provide, and for other healthcare operations. Healthcare operations generally include those activities we perform to improve the quality of care. We have prepared a detailed HI PAA-NOTICEO F PRIVACYP RACTICESto help you better understand our policies in regard to your personal health information. You have the right to review and retain a copy of this notice prior to signing this acknowledgement. The terms of this notice may change with time and we will always have copies available for distribution. I acknowledge that I am aware of HIPAA and, if requested, have been provided with the noticE of the Privacy Practice.

Henry Ford Health System

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