FINANCIAL POLICY

    Orthotics & Prosthetics Services and its affiliates will verify insurance benefits as a courtesy. However

     

          • Insurance coverage is not guaranteed
          • Payment is based on your individual plan
          • Some items may be non-covered.

     

    I understand:

     

          • I am responsible for any unpaid balance
          • Payment may be required prior to or at time of service
          • Non-covered items are the patient’s responsibility

     

    Patient name / Responsible Party : (*)

     

    Your email (*)

     

    Date (*)

     

     

    Please ensure that all information is correct and try to submit the form until you receive a successfully delivered message, thank you.


    Financial Policy Form / ver. 0.1 / Abr-2026