Payment and Policy Agreement
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.
Patient Complaint Process
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.
I have read and agree with the Payment and Policy agreement. I also certify the information provided by me is true, accurate and complete to the best of my knowledge.