The Board of Podiatric Medical Examiners wishes to inform you that, under the law of Maryland, you may not be charged a fee for podiatric goods or services which have been advertised as "free". Nor may you be charged more than the "reduced or discounted" fee advertised for particular podiatric goods or services. In addition, before a podiatrist may charge you a fee to treat immediately or within 72 hours a problem diagnosed at the time you received free, reduced, or discounted podiatric goods or services, you shall consent in writing to accept that treatment. The podiatrist shall explain to you whether he or she thinks that you need the treatment immediately or within 72 hours, or whether your condition does not require immediate treatment. The decision to accept treatment immediately or at a later date is always your decision. If you desire to accept treatment immediately or within 72 hours of today, please sign this document as required by law. Please be aware that you may be financially responsible for payment for the goods or services you receive.
/ /This podiatrist has explained to me the diagnosis of my condition and I understand it. / /This podiatrist has explained the treatment alternatives and their risks to me and I understand them. / /This podiatrist has explained the likely cost of each of the treatment alternatives and I understand it. / /This podiatrist has explained to me the treatment he or she believes I need and I understand it. / /This podiatrist has explained to me why I need the treatment immediately (within 72 hours of today) and I understand it.
I have received my free, reduced, or discounted goods or services. I am accepting treatment today or within 72 hours of today's date and I fully understand that I may be charged for the treatment rendered.
_____________________ __________________________________________ DatePatient's Signature __________________________________________ Witness' Signature __________________________________________ Podiatrist's Signature
Md. Code Regs. 10.40.06.05