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REGISTRATION FORM
LIMITED WARRANTY

REGISTRATION FORM

PATIENT INFORMATION

 

INSURANCE INFORMATION

 

Worker's Compensation

 

IN CASE OF EMERGENCY

 

CONSENT TO RELEASE MEDICAL RECORDS

  • I am requesting release of my medical records to BioTech Limb and Brace, LLC. This form services as authorization to release any medical records requested by Bio Tech to aid in securing payment for my orthosis/ prosthesis or for clinical treatment decisions. This consent is given freely and with full knowledge of the purpose of the release.

    The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize BIOTECH LIMB AND BRACE, LLC or insurance company to release any information required to process my claims.
 

LIMITED WARRANTY

BIOTECH LIMB & BRACE, LLC LIMITED WARRANTY

  • Your Prosthetic I Orthotic device is guaranteed to be made to the individual measurements, proper alignment and proper fit, corresponding with the anatomical conditions at the time of measurement.

    BioTech Limb & Brace, LLC ("the Company") warrants each device to be free from defective workmanship and I or parts, under normal service and use, for six months from the delivery date. The Company's obligations under this warranty are limited to repair or replacement, at no charge, of the part(s) determined defective by the Company. However, this warranty does not cover prosthetic skin coverings, adjustments needed due to anatomical or other medical changes, or accessories (such as prosthetic socks, straps, etc).


    This warranty becomes void immediately, if:


    1. the device has been adjusted, repaired, or altered by anyone other than T and active employee of Bioech Limb & Brace, LLC;
    2. the device or any of its parts have been subject to misuse, negligence, or accident; or
    3. the patient fails to fulfill "Patient Responsibilities," as outlined below.

    Any claim in connection with a device under this warranty shall be limited to the purchase amount.


    PATIENT RESPONSIBILITIES

    The patient must fulfill the following responsibilities:


    1. Keep all appointments when possible, including routine follow-up visits at least every six months.
    2. Inform the Company of any change in overall health which may affect the wearing of the prosthesis or orthosis.
    3. Inform the Company of all medications being taken.
    4. Within thirty days after delivery of the prosthesis or orthosis, inform the Company if any adjustments are necessary. Failure to do so will constitute a waiver by the patient of any claim with respect thereto.

    • PATIENT ACKNOWLEDGEMENT & VALIDATION OF RECEIPT

  •                                     I,
  • understand this warranty and agree to abide by the patient's responsibilities. I attest that I have received the above orthotic or prosthetic device I service(s) prescribed by my physician and provided by BioTech Limb & Brace, LLC.

    • Receipt for HIPPA Privacy Notice (MRIOO)

  • By signing below I acknowledge receipt of a HIPPA Privacy Notice (MR100) from Biotech Limb and Brace, LLC. The terms of this form may change from time to time. I may receive an updated copy of this form by requesting it form the office. The form may be mailed or faxed to me at my request.
  • I authorize the following person to communicate with Bio Tech Limb and Brace, LLC on my behalf.
 
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