FINANCIAL AGREEMENT

Thank you for choosing Baby Bear Clinic for your child’s orthotic care! We are committed to your child’s treatment being a success. Please understand that payment of your bill is considered a part of your child’s treatment and makes it possible for us to remain a viable pediatric orthotic practice. Please read this form carefully and familiarize yourself with the information. A signed financial policy on file is required prior to any treatment. If you have any questions, please do not hesitate to ask.

_______1. Payment for treatment is due at the time of ordering for all devices.  Any custom-made or custom-fit devices cannot be returned or refunded, nor is there reimbursement for shortened treatments. Once ordered, you are responsible for the full payment, regardless of treatment outcomes. We accept cash (exact amount), checks, and credit card. 

_______2. Private-Pay Options: Families who choose to bypass insurance authorization and processing may opt for private-pay. In these cases, a 50% private-pay discount is applied to usual and customary pricing. 

_______3.Fees:

- Returned Checks: $45 fee applies. Future payments must be made via cash or credit card.
- Medical Records: Free for the first 25 pages; $1 per additional page. Payment is required upon pickup. There will be a $45.00 service charge for all returned checks. Returned checks must be picked up immediately with cash or cashier’s check. 

_______ 4. It is imperative that you provide all the necessary information to file claims on your behalf. This will include the insured’s personal information, a valid medical insurance card with a phone number to verify benefits and a correct mailing address. If this information is not available at the time of the appointment or the insurance company can not confirm eligibility, you will be responsible for payment in full at the time device is provided.

Please note that many orthotic devices require prior authorization, which cannot be completed until we have seen your child, collected necessary data, and obtained documentation from the referring physician, and have all necessary insurance information.

_______ 5. As a courtesy, we will submit a claim to your insurance for IN-NETWORK benefits. Please understand your insurance benefits are a contract between you and your employer and it always suggested that you call them if you have questions about your coverage.

You are required to submit OUT-OF-NETWORK claims with payment in full required prior to ordering the device. In special circumstances, we may submit for out-of-network claims. 

_______ 6. If your insurance deems our services to be non-covered, you will be
responsible for the full cost of the device.

_______ 7. The parent or guardian who brings the child for his/her visit is legally responsible for payment independent of what a divorce decree may state. We will not send statements to other persons. Reimbursement must be made between the divorced parents, we will not intervene. Please make payments to the office in advance if someone other than the parent/guardian will be bringing your child to the appointment.

_______ 8. The office can not carry balances over 90 days: regardless of insurance. Delinquent accounts can be charged a 1.5% per month or 18% per yr. finance charge. If it becomes necessary for your account to be sent to an outside collection agency or small claims court, please note you will be responsible for all applicable fees, charges and attorney costs.

_______ 9. All devices are custom-made and cannot be returned or refunded. This is non-negotiable. Once ordered, you are responsible for the full payment, regardless of treatment outcomes. For cranial remolding helmets, the FDA mandates a 14-day timeframe from ordering to fitting: if an appointment is canceled, rescheduled, or missed, causing the delivery to exceed the 14-day window, the patient may be responsible for the device cost, even if the device is not delivered.

I acknowledge and accept full financial responsibility for all charges for services or items provided to the minor/child. I understand any insurance estimate given by this office is not a guarantee of actual insurance payment or coverage and understand filing a claim with my insurance benefit plan does not relieve me from my responsibility for the payment of all charges. I assign dental benefits to be paid directly to Baby Bear Cranial Clinic, LLC.

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