Patient Privacy and Billing Notices

"The products and/or services provided to you by Palmetto O&P are subject to the supplier standards contained in the Federal regulations shown at 42 Code of Federal Regulations Section 424.57(c). These standards concern business professional and operational matters (e.g., honoring warranties and hours of operation). The full text of these standards can be obtained at http://ecfr.gpoaccess.gov. Upon request, we will furnish you a written copy of the Medicare Supplier standards." There is a current copy for viewing on our front office wall.

I acknowledge that I did receive and either have read or will read the “Patient Bill of Rights”, “Warranty”, “Billing & Collection Policy” and “What goes into the cost of my orthosis/prosthesis?”

I authorize Palmetto O&P to act on behalf in helping me obtain payment from my insurance companies. I authorize payment directly to Palmetto. I authorize the use of this form on all my insurance submissions. I permit a copy of this authorization to be used in place of the original.

I understand that I am personally, financially responsible for the charges, (including any amounts towards deductible(s) or for non–covered products by Medicare or my insurance company) for products and services provided to me, my spouse and my minor children. This includes services for which Medicare, or my insurance company has paid me directly. I understand this authorization will remain in effect until I revoke it in writing.

I request that payment of authorized Medicare benefits be made on my behalf to Palmetto O&P. I understand that my signature requests that payments be made to Palmetto O&P and understand the use and release of my medical records as described above. By accepting Medicare Assignment, Palmetto O&P agrees to accept the charge determination of the Medicare carrier as the full charge and the patient is responsible only for the deductible, co-insurance, and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier.

I authorize staff of Palmetto O&P to contact me by Phone, SMS and E-mail regarding various aspects of my medical care, which may include, but shall not be limited to appointments and product reminders. I understand that E-mail and standard SMS messaging are not confidential methods of communication, may be insecure and there may be a risk that a third party may read my message.