Acton Foot And Ankle LLC

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(978) 635-0229

179 Great Rd Ste 101, Acton, MA 01720

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  • We require co-payment at time of service. We accept-cash, checks, Visa, Mastercard, and Discover.
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  • SIGNATURE OF FILE AND PERMISSION TO TREAT

    • I understand that the information provided on this form is true and correct to the best of my knowledge.
    • I request that payments of authorized benefits be made on my behalf for any services furnished by Acton Foot and Ankle.
    • I authorize any holder of information about me to release any information needed to determine these benefits or the benefits payable to related services to the insurance agent.
    • I recognize my financial obligation of an co-insurance, co-payments, or deductibles and non-covered services that may be required.
    • I hereby give permission to Acton Foot and Ankle and any qualified staff to evaluate, diagnose and treat my foot and/or ankle condition as may be deemed necessary
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Acton Foot And Ankle LLC

Phone: (978) 635-0229 Address: 179 Great Rd Ste 101, Acton, MA 01720

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