Orthotics payment Medical Form

Podiatrist

I, _________________________________________ have agreed to have custom orthotics made. If my insurance does not pay for the orthotics, I realize that I am responsible for payment of the devices upon receipt of the orthotics unless other payment arrangements have been made. If the orthotics are paid upon receipt I agree to pay $400.00, utilizing our “Quick Pay” discount. I have agreed to make a down payment of $100.00 to be held by Big Rapids Foot & Ankle. This amount will be held in the event that I do not pick up my orthotics within 1 month of notification that they have been completed. After 1 month, I will then be charged the $100.00 down payment. If I feel the custom orthotics have not given adequate relief and they are returned within thirty (30) days of receiving them, I will receive a credit of $200.00 as these are custom devices and cannot be used for another individual. We must receive the orthotics in order to obtain credit. Check or Credit Card number: _____________________________________________________ Expiration date: __________________________ Security code: __________________________ Signature _______________________________________________ Date __________________

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Published: March 1, 2021, 3:56 p.m.
Doctor: Dr. History Physical
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