Patient Financial Responsibility Statement printable pdf download

Comfort Prosthetics & Orthotics

Patient Financial Responsibility Statement

1. Insurance. We participate in most insurance plans, including Medicare. However, unless you carry

secondary insurance there will likely be a deductible, and the percentage reimbursed by your insurance

carrier may not equal the amount billed for services rendered, in which case the patient is responsible

for any balance due.

2. Co-payments and deductibles. All co-payments and deductibles must be paid to Comfort Prosthetics

& Orthotics, this arrangement is part of your contract with your insurance company. Failure on our part

to collect co-payments and deductibles from patients can be considered fraud. Please help us in

upholding the law by paying your co-payment in a timely fashion.

3. Proof of insurance. All patients must complete our patient information form before seeing their O&P

professional. We must obtain a copy of your driver’s license and current valid insurance to provide proof

of insurance. If you fail to provide us with the correct insurance information in a timely manner, you

may be responsible for the balance of a claim.

4. Claims submission. We will submit your claims and assist you in any way we reasonably can to help

get your claims paid. Your insurance company may need you to supply certain information directly. It is

your responsibility to comply with their request. Please be aware that the balance of your claim is your

responsibility whether or not your insurance company pays your claim. Your insurance benefit is a

contract between you and your insurance company; we are not party to that contract.

5. Coverage changes. If your insurance changes, please notify us before your next visit so we can make

the appropriate changes to help you receive your maximum benefits. If your insurance company does

not pay your claim due to unreported changes, you will be held responsible for the unpaid balance.

6. Cancellation Policy. Comfort Prosthetics & Orthotics confirms all appointments 24-48 hours in

advance, if we do not receive positive confirmation from each patient one day before a scheduled

appointment, or you are more than 15 minutes late for an appointment, we reserve the right to cancel

it. This policy results in fluid, attentive care that respects each patient equally.

Signature:_________________________________________________________Date:_______________

Patient Financial Responsibility Statement