Orthotic Prosthetic Solutions is a partnership of board certified practitioners. OPS takes pride in providing quality
orthotic and prosthetic devices. Our warranty period for custom orthotics and prosthetics on workmanship and
materials is 3 months from the day you take the device home. OPS cannot be responsible for physiological,
pathological, or anatomical changes in a patient’s medical condition, although we will attempt to maintain proper
fit during this period. At the discretion of the practitioner, normal adjustments will be made for a period of one
year. Any additions prescribed by a physician will have an additional charge. Adjustments, repairs, or need of
replacement incurred as a result of excessive wear, i.e. sports, certain work activities, will have an additional charge.
A physician has prescribed custom orthotics and prosthetics. Custom, means it is made to fit specifically for your
body. They cannot be returned for credit or refund. Off-the-shelf items cannot be returned for hygienic reasons. If
you are having any difficulty with the fit of your device, please be sure to call the office and we will get you in as
soon as possible for adjustment.
OPS will make every effort to verify your benefits and bill your insurance. Ultimately it is your responsibility to know
your benefits. It is always a good idea to call your insurance and check your benefits yourself. Insurance
companies have a disclaimer that the statement of benefits is not a guarantee of payment. This means that you
may have benefits, but the insurance may not pay for the device if they deem it not medically necessary. If after
processing the claim, they decide to not pay OPS, OPS will be billing you. Deductibles and co-payments are your
responsibility, and OPS will collect this from you at the time of delivery of the device.
I certify that I have reviewed a copy of Notice of Privacy Practices. The Notice of Privacy Practices describes the types
of uses and disclosures of my protected health information that might occur in my treatment, payment of my bills,
or in the performance of OPS health care operations. The Notice of Privacy Practices also describes my rights and
OPS’s duties with respect to my protected health information. OPS reserves the right to change the privacy
practices that are described in the Notice of Privacy Practices. I may obtain a revised Notice of Privacy Practices by
calling the office and requesting a revised copy be sent in the mail, or asking for one at the time of my next
I hereby authorize Orthotic Prosthetic Solutions to release necessary medical information to my insurance to
process my medical claim. I authorize my insurance carrier to pay benefits directly to Orthotic Prosthetic
Solutions on my behalf for any services furnished me by Orthotic Prosthetic Solutions. I authorize any holder
of medical or other information about me be released to the Health Care Financing Administration and its
agents to determine the benefits for services provided.
I, the undersigned, have read and understand these policies and agree to all the above.
MEDICARE PATIENTS ONLY: I acknowledge that I have reviewed a copy of the Medicare Supplier Standards.