Responsible Party for Insurance Billing and Services:
First Name (required)
Last Name (required)
Email Address (required)
Relationship to Patient
Emergency Contact Name
Emergency Contact Telephone
Emergency Contact Relationship to Patient
Name of Insured if Not Patient
Subscriber/Insured Party Date Of Birth
Name of Insured
Subscriber Date of Birth
All professional services rendered are charged to the patient. Necessary forms will be completed to help expedite insurance coverage. It is also customary to pay for services when rendered unless other arrangements have been made with our office.
Insurance authorization and assignment:
I hereby authorize Napa Solano Foot and Ankle to furnish information to insurance carriers concerning my illnesses and treatments and to my referring physician if so requested. I hereby assign to the physician all payments for my medical services rendered to myself or my dependents. I understand that I am responsible for any amount not covered by my insurance.
May we use photographs taken of your feet for educational purposes only?
Napa Solano Foot & Ankle
1460 North Camino Alto, Suite 101
Vallejo, CA 94589
Phone: (707) 644-4049
Fax: (707) 644-4687
935 Trancas Street, Suite 2C
Ph: (707) 259-0766
Fax: (707) 259-0183