Dynasplint — Legal
If you are a patient and the Dynasplint reps comes to your home to give you a splint DO NOT SIGN ANY FORMS. I'm a lawyer and needed a splint that of course my insurance wouldn't cover and the rep wanted me to sign this form. Legally it binds you financially responsible for all costs assocaited with the Dynasplint. A good company would write off what was not collected, medical companies do it all of the time. Don't be scammed into signing this form. I have posted the verbiage so you don't get taken for a ride. Here's the wording:
I understand that the insurance benefit plan under which I have health coverage will only pay for the use of the Dynasplint® System that has been prescribed for me by my physician for a period of up to four (4) months.
Furthermore, I acknowledge that it has been explained to me by Dynasplint Systems, Inc. (DSI) that I may require the use of the Dynasplint® System longer than four (4) months. Therefore I, _________________________, agree to accept financial responsibility for the use of the Dynasplint® System that I have received today for anyperiod of time for which my insurance will not cover its use under the following terms and conditions:
I agree to rent the Dynasplint® System with serial number ___________________ for $__________ per month for any period of time that I utilize the Dynasplint® System for which my insurance will not authorize or pay for its use. For every month or portion thereof until I return the Dynasplint® System to DSI a claim will be submitted to my insurance. If the claim is denied as it is expected to be, I will be billed for the charge that is
not covered. I understand that all billing will occur in accordance with the terms of the contract between DSI and my insurance, if one exists, or in accordance with DSI’s standard practices.
My signature represents understanding and agreement with all terms stated herein.
Don't be taken for a rocky financial ride. My ortho will be getting as copy of this and I believe will cease his ordering of this product.