HIPAA & Bill of Rights
WARRANTY POLICY
The warranty period for custom prostheses is three months for workmanship and materials. Although Perry Prosthetics, Inc. cannot be responsible for physiological or anatomical changes in a patient's medical condition, we will attempt to maintain a proper fit during this period. Normal adjustments to enhance fit will be made at the discretion of the practitioner at no charge for up to three months after delivery of the device. There will be a chance for adjustments or repairs that are made as a result of physiological or anatomical changes, as well as abuse or tough wear. Additions of components prescribed by a physician will incur a charge. Prostheses are described at the direction of a physician and are custom fabricated. They cannot be returned for credit or refund. Prescribed "off the shelf' items cannot be returned for hygienic reasons. Please communicate any problems or discomfort you are experiencing to your practitioner immediately.
PAYMENT POLICY
Perry Prosthetics, Inc. will bill your insurance company as a courtesy to you; however, we are not responsible for non-payment from the insurance company. Payment for all medical services furnished are the responsibility of the patient. Deductibles, co-insurance and payment for noncovered services are due upon receipt of invoice. If you are unable to pay your balance in full, we will work with you personally to develop a payment plan consisting of monthly payments that suit your financial means. Perry Prosthetics, Inc. can in no way guarantee coverage. Benefits are determined by your insurance at the time your claim is processed. It is your responsibility to know your benefits. We strongly advise you to contact your insurance company to check your benefits/coverage. Payments may be made by cash, check, credit card or money order.
PATIENT APPOINTMENTS
Patient care is the top priority at Perry Prosthetics, Inc. to better accommodate our patients, return and follow up appointments will be scheduled at the end of each appointment. if you must cancel or reschedule an appointment, we ask that you do so as far in advance as possible. If an appointment is missed without prior notification, the patient will be billed at $45.00 missed appointment fee.
PATIENT COMPLAINT PROCESS
We are committed to ensuring you are completely satisfied with the services and care you receive at Perry Prosthetics, Inc. however, if for any reason you wish to file a complaint, any staff member can assist you in this confidential matter. You will be asked to complete a "Patient Complaint Form" to assist us in understanding your complaint. Once the form is received, a company representative will investigate the complaint thoroughly and take the necessary actions to satisfy your complaint.
ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES & SUPPLIER STANDARDS
I certify that I have reviewed a copy of Perry Prosthetics, Inc. Notice of Privacy Practices. The Notice of Privacy Practices describes the type of uses and disclosures of my protected health information that might occur in my treatment, payment of my bills or in the performance of Perry Prosthetics, Inc. health care operations. The Notice of Privacy Practices also describes my rights and Perry Prosthetics, lnc.'s duties with respect to my protected health information. Perry Prosthetics, Inc. reserves the right to change their 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 copy be sent by mail or asking for one at the time of my next appointment. I acknowledge that I have received a copy of the Medicare Supplier Standards.
ASSIGNMENT OF BENEFITS
I hereby authorize Perry Prosthetics, Inc. to release necessary medical information to my insurance to process my medical claims. authorize my insurance carrier to pay benefits directly to Perry Prosthetics, Inc.
I requested that payment of authorized Medicare benefits be made to Perry Prosthetics, Inc. on my behalf for nay services furnished by me by Perry Prosthetics, Inc. I authorize any holder of medical or other information about me to be released to the Center of Medicare & Medicaid Services and its agents to determine these benefits. As the responsible party, I understand that I am personally responsible for the entire amount of my claim and that insurance benefits may be limited or non-existent.
