Round Rock Orthotics & Prosthetics, Inc.
555D Round Rock West Drive, Suite 100 Round Rock, TX 78681 Office (512) 341-3700 Fax (512) 341-3738 firstname.lastname@example.org www.rropinc.com
Thank you for choosing Round Rock Orthotics & Prosthetics, Inc. We are committed to the success of your care and ensuring that you receive the best orthotic and prosthetic care available. Your success is our success! Please read the following information carefully. We encourage you to speak with our staff should you have questions.
Payment is due at the time of service. We accept cash, checks, Visa, MasterCard, American Express and Care Credit. Should you choose to make payment to Round Rock Orthotics & Prosthetics, Inc. by check and it is returned, a fee of $35.00 will be charged to your account. I understand that I may be charged the full price of an office visit ($50.00) if I fail to notify Round Rock Orthotics & Prosthetics, Inc. of cancellation less than 24 hours prior to any scheduled visit.
I request that payment of authorized Medicare, Medicaid, or private insurance benefits be made to Round Rock Orthotics & Prosthetics, Inc. for any covered services furnished by Round Rock Orthotics & Prosthetics, Inc. I understand I am responsible for payment to Round Rock Orthotics & Prosthetics, Inc. for deductible and/or coinsurance on my claim or any of my dependent(s I further agree that should the amount be insufficient to cover the entire orthotic or prosthetic expense, I will be responsible for payment of the difference, and if the nature of the disability be such that it is not covered by the policy, I will be responsible to Round Rock Orthotics & Prosthetics, Inc. for payment of the entire bill. Failure to resolve account balances within 90 days could result in my account being transferred to Merchants & Professional Credit Bureau, Inc. for further collection activity unless payment arrangements are in place. I will then be held responsible for all collection fees incurred including, but not limited to, lawsuit filing fees, service of process fees, attorney's fees, and all other legal fees and costs because of this action in addition to my outstanding balance with Round Rock Orthotics & Prosthetics, Inc.
I also understand that telephone, fax or online inquiries to my insurance company ARE NOT a guarantee of coverage/benefits. We (Round Rock Orthotics & Prosthetics, Inc. have attempted to estimate your balance due; however, after review by your insurance company, you may owe an additional amount.
I authorize any holder of medical information about me to release all information needed to determine benefits or the benefits payable for related services. This is to include, but not limited to Centers for Medicare & Medicaid Services (CMS) and its agents, TRICARE and its agents, VA and its agents or to any private insurance company.
I further certify that the information provided by me is true, accurate and complete. If this is a private insurance claim, I further agree to be responsible for the full amount of the charges from the date of delivery if my private insurance company does not pay for the charges in a timely manner, or my practitioner or I fail to provide within (30) days the information necessary to submit the claim for payment.
I understand that custom fabricated items retain no salvage value and that Round Rock Orthotics & Prosthetics, Inc. reserves the right to bill my insurance company once the item has been completed regardless of whether I return for the fitting and any out of pocket expenses due become my responsibility.
I understand that the date of service used to bill my claim to insurance or responsible parties, including myself is the date of delivery. Date of delivery is the day that my device(s) are delivered to me and acknowledged by my signing a Receipt of Device, also known as a Delivery Receipt. The date of delivery is NOT the date of evaluations, castings/impressions, repairs or adjustments.
I understand that devices regularly require adjustments and/or repairs. I understand that Round Rock Orthotics Prosthetics, Inc. has been mandated by Centers for Medicare and Medicaid Services (CMS) to bill parts, labor and repairs to my insurance company and/or responsibility party. The need for adjustments, repairs and replacement parts is expected with normal use and typically should not be considered poor workmanship. In the event poor workmanship is the cause, Round Rock Orthotics & Prosthetics, Inc offers a 90-day warranty from the date of delivery.
By initialing, I acknowledge that I have read and understand all financial policies.