When a patient is cast for orthotics, it is our policy to always bill the patient's insurance. However, whatever expenses are not covered by insurance must be paid by the patient.

It is the patient's responsibility, if they so wish, to call their insurance provider to ascertain if there is coverage for custom orthotics. Any CPT codes the insurance provider may request are listed in the Orthotics Information Manual.

A required casting fee of $120.00 must be paid by the patient at the time of casting in order to initiate the process unless other arrangements have been made.

$260.00 will be collected from the patient when the new orthotics and casts are ready to be picked up. If, after that time, some payment is received from the insurance company, a refund equal to the amount paid toward the orthotics by the insurance company will be sent to the patient.

If a patient has called their insurance provider, and has been informed custom orthotic coverage is provided, the patient may wait until that payment has arrived before picking up their orthotics. At that time any remaining amount not paid by the insurance is due from the patient. (Please note, it can take up to three months for payment to be received from an insurance provider.)

I have read the above written casting policy and agree to its terms.

Patient's Name _______________________________________

Date _______________________________

Patient's Signature ____________________________________