Your insurance policy is a contract between you and your insurance company to help you meet medical expenses. Because benefits can vary greatly, it is not possible
for Bulow Orthotic & Prosthetic Solutions to provide services on the basis that your insurance company will pay all charges.
Bulow Orthotic & Prosthetic Solutions can in no way guarantee coverage. Benefits are determined by your insurance plan at the time your claim is processed. All
benefit calculations are only an estimate, based on information obtained from your insurance company. The actual Total Patient’s Responsibility may be different than
what was previously estimated by Bulow Orthotic & Prosthetic Solutions.
To prevent any misunderstanding about medical insurance, we wish to point out that: (1) Payment for all medical services furnished are the responsibility of the patient; (2) Deductibles, co-payments, and/or other patient responsibility amounts are due at the time services are rendered; (3) For deductibles, co-insurance and non-covered custom-made devices
fifty percent (50 %)
of the balance is due at the casting appointment, with the balance due at the time of delivery; (4) Bulow Orthotic & Prosthetic Solutions will bill your insurance company as a courtesy to you; however, Bulow Orthotic & Prosthetic Solutions is not responsible for non-payment from the insurance company; (5) If, due to unforeseen circumstances, additional procedures and/or treatments are necessary beyond what has been previously approved, patients must make arrangements for payment; (6) Patients are expected to keep their accounts current while waiting for their insurance company to remit payment.
In consideration of The Company’s efforts to supply patients with products and/or services to the patient, the patient or guarantor agree that each of them is responsible
for payment. Payments may be made by check, money order, Visa or MasterCard. A $20.00 fee will be assessed for any check returned for any reason.
NO REFUNDS will be given for the following items: CUSTOM MADE ITEMS, PROSTHETIC SUPPLIES (LINERS, SLEEVES, SOCKS), NONSTOCK,
and SPECIAL ORDER ITEM. All other items will be reviewed on a case by case basis.
We are committed to ensuring you are completely satisfied with the services and care you receive at Bulow Orthotic & Prosthetic Solutions. However, if for any reason
you wish to file a complaint, any staff member can assist you in this confidential matter. You will be asked to complete a “Patient Complaint Form” to assist us in
understanding your complaint or concern fully. Once the form is received, a company representative will investigate the complaint thoroughly and take the necessary
actions to satisfy your complaint.
By signing below, I certify that Bulow Orthotic & Prosthetic Solutions, its parent company & its subsidiaries (“The Company”) has made
available to me a Notice of Privacy Practices. The Notice of Privacy Practices describes the types of uses and disclosures of my
protected health information that might occur in my treatment, payment of my bills or in the performance of Bulow Orthotic &
Prosthetic Solutions healthcare operations. The Notice of Privacy Practices also describes my rights and The Company’s duties with
respect to my protected health information. Bulow Orthotic & Prosthetic Solutions reserves the right to change the privacy practices
that are described in the Notice of Privacy Practices. I may obtain a revised Notice of Privacy Practices by calling the office and
requesting a revised copy be sent in the mail, or asking for one at the time of my next appointment.
I, the undersigned, consent to be contacted by The Company by phone call, e-mail, US Postal Service or other means to follow-up on my care.
By signing below, I understand that Bulow Orthotics & Prosthetic Solutions may use my likeness in a photograph or video as part of
its marketing efforts including but not limited to publication in external communication and social media posts. I waive the right to
inspect or approve the finished product wherein my likeness occurs. Additionally, I waive any right to royalties or other
compensation related to the use of those images.
I understand that by signing this agreement, I indicate my wish to purchase orthotic and/or prosthetic products or services, or both,
from The Company. I understand that I am under the supervision and care of my attending physician. I understand that my physician
has prescribed the orthosis/prosthesis noted as part of my treatment. I also understand that due to the nature of the products supplied
by The Company that they cannot be returned.
I, the undersigned, hereby authorize The Company to request on my/our behalf and to collect directly all public and private insurance
benefits due for products and/or services supplied to me by The Company. In the event payments for insurance benefits are made
directly to any of the undersigned, the payee will endorse to The Company all checks for such payments.
By signing below, I authorize all medical personnel to provide information to The Company concerning my medical history, as it may
relate to my treatment. This includes collecting medical information from any physician, surgeon, medical facility and/or physical
therapist seen by me. The Company will comply with all HIPAA rules and regulations.