TFCZ01 Orthotics Service Agreement

Patient Orthotic Service Agreement

Patient Name*

First NameMiddle NameLast Name

Date of Birth*

Date

All payments for orthotics are the sole responsibility of the patient.

Any insurance coverage is a contract between you and your insurance
carrier. It is your responsibility, as the patient, to confirm whether your
insurance carrier covers the prescription custom orthotics, and whether they
cover the full amount.

Payment is due at the time of service.

We require a deposit of $197.50 at the time your feet are casted for your custom medical orthotics. The remaining $197.50 is due at the dispense appointment.

The amount billed for the custom medical orthotics (L3000) is $395.00 per pair ($197.50 each foot) – this may exceed the cost that your insurance will allow. The cost for a second pair of orthotics is $250 if they are ordered within six months of the original casting.

By signing below, I have read the above information and understand that I am responsible for payment of all costs for my prescription orthotics. If a pre- authorization is necessary in order for insurance to pay for the orthotics, then I have confirmed that there is a pre-authorization. If necessary pre-authorization is NOT on file, then I accept full responsibility for payment.

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Patient/Guardian Signature*

Name

First NameLast Name

Date