Thank you for choosing Capital Prosthetic and Orthotic Center, Inc as your healthcare provider. The following is a statement of our billing policy and Patient Service Agreement.
Capital Prosthetic and Orthotic Center, Inc. agrees to bill your insurance carrier only if ALL NECESSARY INFORMATION IS PROVIDED. If a minor is unaccompanied he/she should have payment/insurance information with them or prior arrangements should be made. The adult accompanying a minor is responsible for payment. If your insurance requires a REFERRAL or PRIOR AUTHORIZATION,these MUST be in place before services are rendered. Should your insurance NOT COVER the services provided, the balance is YOUR RESPONSIBILITY. If your insurance company has not paid your account within 60 days, the balance will be automatically transferred to you and become your responsibility. A statement will be mailed to you and payment is expected upon receipt. Any credits will be issued upon request. Capital Prosthetic and Orthotic Center, Inc. is not responsible for any incorrect information that your insurance company may give resulting in non-payment of any portion of your claim. If this occurs, you will be responsible for payment. Your insurance policy is a contract between you and your insurance company. COVERAGE CANNOT BE GUARANTEED. You will need to contact your carrier with any problems or questions.
We accept cash, personal checks, money orders, major credit cards (Visa, MasterCard, Discover, American Express) and CareCredit. If necessary, a payment plan can be arranged. (*Should you make payment by check and it is returned, a fee of $20.00 will be charged to your account.) If incorrect information is given to Capital Prosthetic and Orthotic Center, Inc. resulting in non-payment of service(s), the patient/responsible party will be responsible for payment is full of said service(s). Any “patient pay” responsibilities are due at time of service. Please ask if you need to request an Economic Hardship.
Custom items require a 50% down payment BEFORE
ordering. Delivery must take place within 60 days of ordering. The remaining 50% will be due upon receipt. It is not always possible to match materials or colors but please know that Capital Prosthetic and Orthotic Center, Inc. will come as close as possible to your device needing custom work.
ALL ITEMS ARE NON-RETURNABLE AND NON-REFUNDABLE. Capital Prosthetic and Orthotic Center, Inc. is filling the prescription written by your physician. There is no guarantee this item will alleviate your symptoms. For special order products, a 15% restocking fee will be charged if you choose not to be fit with the item. If there is a request for an item to be mailed, the same rules apply.
Depending on the level of service a Follow-Up appointment will be scheduled for 1-6 weeks after you are delivered to see how things are going. This will give you an opportunity to try out your new device.
Insurance companies, as well as our continuous effort to improve services, you are encouraged to complete a customer satisfaction survey. Your feedback is instrumental for improving organization performance as well as payment from your insurance company.
Capital Prosthetic and Orthotic Center, Inc.
supports open communication with our patients. Please feel free to contact Lisa Crawford, General Manager 614-451-0446
if you do not feel you were treated professionally.
You authorize any photography of yourself and / or your device by Capital Prosthetic and Orthotic Center, Inc in connection with diagnosis, treatment, or for reimbursement purposes. Photographs will be incorporated within the patient’s medical record for documentation of care.
As patient or responsible party for patient, I agree to pay for all services rendered in accordance with the terms and conditions set forth in the financial policy.
- I authorize my insurance company to pay benefits directly to Capital Prosthetic and Orthotic Center, Inc. I understand my insurance company may not pay for services that are not a covered benefit or are not considered medically necessary, I also understand that there may be benefit limitations with no-fault carriers as deductibles and benefit maximums may apply. I agree to be financially responsible for all services provided by Capital Prosthetic and Orthotic Center, Inc.
- I have been offered Capital Prosthetic and Orthotic Center, Inc’s Notice of Privacy Practices and consent for use and disclosure of my PHI to carry out treatment, payment activities, and healthcare operations.
I have read, understand, and agree to the terms and conditions listed above.
