New Patient Information

>>>PDF Patient Intake Forms<<<

• In order to fill a prescription, the person the item was prescribed for MUST be present for the fitting. Minors MUST be accompanied by an authorized adult.

• Must have a valid ID and current insurance card.

• Services rendered and payment for services, are based on the insurance information provided at the time of service and the validity therein. It is solely the responsibility of the patient/insured to notify us of any changes in insurance coverage prior to the delivery of your prescribed item.

• We may NOT be contracted or in-network providers for your insurance carrier. As a courtesy, benefits and eligibility will be verified to disclose to you your in-network vs. out of network coverage if applicable. The choice will be given to you to decide if you want services rendered by us or contact your insurance carrier to refer you to an in-network/contracted provider.

• Please read the Proof of Delivery Form for further financial obligations that may be incurred. Although you have insurance coverage and the prescribed item is a covered benefit and has been approved by your insurance carrier, it is not always paid by your insurance for one reason or another. This is usually not known until claim has been filed. This may be in addition to your required copay.

• All co-pays, deductibles or out of pocket expenses are DUE AT THE TIME OF SERVICE. We may discuss possible payment options as well, however be aware a deposit is required.

• Please be sure to complete all sections and questions on the required forms and sign and date where indicated. Incomplete forms or missing information may be requested to be completed prior to the provision of services.

Should you have any questions regarding the above, please inform our office staff.
Thank you kindly.
Advanced Prosthetics and Orthotics

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