The Patient acknowledges receipt of the equipment or services described on the delivery ticket, on the service date indicated.

Patient understands their insurance company may have a lower allowable and/or rate they pay and if Journey Orthotics & Prosthetics IS NOT a contracted provider, patient will be held responsible for the difference between the Joint Active System’s Usual & Customary rate and the amount the insurance company has paid, when applicable.

Patient agrees to be financially responsible for all charges incurred as a result of purchasing the equipment listed on the front of this document. Patient also agrees to be financially responsible for any charges denied, rejected, or otherwise not covered by his/her federal, state, or private insurance carriers for any reason, including deductible and co-pay amounts. Patient agrees to a 1.5% per month finance charge on any unpaid or overdue amount.

WARRANTY INFORMATION:

• Returns or exchanges of off the shelf item(s) are only accepted within 14 days of purchase, in the original packaging and in unused condition with the receipt.

• Manufacturer warranties will be honored where applicable.

• All adjustments and repairs to maintain proper function of the item will be provided free of charge during the 90-day warranty period.

• If someone other than Provider or Manufacturer, alters the item(s) the warranty will be voided.

• The warranty does not apply to changes in weight, medical condition, or other physical changes that may occur, or abuse, neglect, or normal wear and tear of the item(s).

Patient authorizes Journey Orthotics & Prosthetics and affiliate agents, assigns or successors to contact me at the telephone number, cellular number and email address the patient has provided in the past, present or future. Patient understands contact to any cellular number(s) may result in an additional data charge. Patient agrees to the methods of contact that may include using pre-recorded or artificial voice messages and/or an automatic telephone dialing systems(s). Patient also understand this prior written express consent is not a condition of receiving treatment or service.

To opt out of this consent, it is the patient’s responsibility to send written notification to Journey Orthotics & Prosthetics.

Patient agrees to inform Journey Orthotics & Prosthetics of any changes such as: Insurance coverage, address, telephone or cellular phone number, email address, any admissions or discharges to/from hospitals and/or nursing homes as needed for treatment.

In executing this agreement, the Patient agrees that the terms and conditions herein shall be binding on my heirs, successors, designated agents, executors, and administrators. If any provision herein is found to be void or unenforceable by a court of competent jurisdiction, the other provisions herein shall remain in full force and effect. This agreement represents the entire agreement between the parties and supersedes all prior oral and/or written agreements and representations. No waiver or modifications of any of the provisions herein shall be binding on the Joint Active Systems, Inc. Patient understands and agrees that this agreement shall be construed in accordance with the laws of the State of Illinois and applicable Federal Laws.

Journey Orthotics & Prosthetics recognizes the patient’s right to privacy and will take all precautionary measures to secure all patient communications, regarding services, to be kept confidential as required by law.