All payments for orthotics are the sole responsibility of the patient.
Any insurance coverage is a contract between you and your insurance carrier. It
is your responsibility, as the patient, to confirm whether your insurance carrier
covers the prescription custom orthotics, and whether they cover the full
amount.
Payment is due at the time of service.
We require a deposit of $197.50 at the time your feet are casted for your custom
medical orthotics. The remaining $197.50 is due at the dispense appointment.
The amount billed for the custom medical orthotics (L3000) is $395.00 per pair
($197.50 each foot) – this may exceed the cost that your insurance will allow.
The cost for a second pair of orthotics is $250 if they are ordered within six
months of the original casting.
By signing below, I have read the above information and understand that I am
responsible for payment of all costs for my prescription orthotics. If a pre-authorization is necessary in order for insurance to pay for the orthotics, then I
have confirmed that there is a pre-authorization. If necessary pre-authorization
is NOT on file, then I accept full responsibility for payment.
Notice regarding Minor Patients: Cost for subsequent pairs of orthotics for minor patients enrolled in the
Outgrowth Policy: $250 until age 18 -Outgrowth enrollment fee: $59
Insurance Claw back Notice: If your insurance is billed for your orthotics due to an insurance requirement
or an audit, our clinic will retain your payment for three (3) years after the date your insurance carrier
adjudicates the claim. This is required due to insurance claw backs, audits, and retroactive recoupments
that may occur up to three years after adjudication. If no claw back or recoupment occurs within that
period, your payment will be fully applied to your account.
