Patient Knowledge of Responsibility 2020 (Form 0416)

Patient Knowledge of Responsibility

Read all options then mark your decision:*

I want my item(s) started today so they are available in two weeks. * I understand if insurance does not pay for my item(s) or if I fail to keep my delivery appointment, I will be billed the full cost of the item(s)I want to keep my appointment today & put my item(s) on hold until insurance is verified and reviewed with me. I understand the $100 I pay today will go towards the cost of the items and the balance will be forwarded to insurance. *I understand that if I decide not to go through with the item(s), the $100 will cover my evaluation ($35)& impression/casting fee ($65).I do not wish to have my item(s) made at this time. *I understand this does cancel my appointment today.

Every Insurance has the following Disclaimer:
Insurance verification and review of benefits is NEVER A GUARANTEE OF PAYMENT. The only time payment is guaranteed is once the claim has been received & processed for payment.

* Due to the above disclaimer, Fred Toenges Pedorthics cannot guarantee your claim will be paid because we verified your insurance.

Additional pair of custom foot orthotics:
Within 90 days of your purchase if you decide you would like to purchase a second pair of custom foot orthotics, they are available at a 20% discount.
*This discount is available for patients that pay fully out of pocket for their first pair of orthotics you may not get a discount if the first pair was filed with insurance.

Full payment or $100 deposit is required for the following:
*Items are not covered by your insurance
*Fred Toenges Pedorthics is not in network with your insurance
*Your benefit maximum has not been met

Patient/Guarantor Signature*

Date*

Date

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Patient Knowledge of Responsibility Form 0416 Rev. 1/20