Orthotic Warranty Form PDF Details

Upon enrolling in the Biomechanical Services’ orthotic warranty program, individuals are embarking on a journey to secure an additional safeguard for their orthotic investments. With a one-time completion of an enrollment form and associated payment, the warranty program introduces an array of benefits set to commence for a two-year period from the date of enrollment. This program not only promises the repair or replacement of orthoses but also ensures the storage of the molds used for their fabrication for the same duration, guaranteeing that adjustments, repairs, and replacements are meticulously managed through one’s prescribing practitioner to adhere to the precise original specifications. Moreover, in instances where orthotics are beyond repair, the program covers the production of a new pair at no additional charge, provided they are returned for evaluation. It recognizes the practicalities faced by users including the unfortunate event of loss or theft, setting a nominal replacement charge per device within the program's tenure, and acknowledges the unique needs of children who outgrow their orthoses, offering replacements for those 17 and younger at no cost. Importantly, the enrollment form acts as the gateway to these benefits, requiring applicants to submit their details alongside a $60 fee to join the extended warranty program, a move that not only protects their orthotics but represents a wise investment in their long-term well-being and mobility. This comprehensive approach underscores the commitment of Biomechanical Services to meet needs and fulfill expectations, anchoring the warranty as a critical component of orthotic care.

QuestionAnswer
Form NameOrthotic Warranty Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesirrepairable, warranty enrollment form, the orthotic group orthdic waranty form, orthoses

Form Preview Example

ENROLLMENT in the biomechanical Services’: orthotic warranty program will provide for repair or replacement of the orthoses made for:

account name:

patient name:

 

orthotic no.:

 

 

 

THE BENEFITS of this warranty program take effect once we receive your completed enrollment

form and payment. the coverage period is for two years from that date. the molds used to fabricate your orthoses will be stored for two years, beginning on your conirmed enrollment date.

biomechanical Services will notify your health care provider of your enrollment. you must enroll within four months of the date printed on this form (see below), beyond that, your foot molds are not available for extended storage.

ADJUSTMENTS, REPAIRS AND REPLACEMENTS will be handled through the prescribing practitioner only, as they will have the most complete records of those indications that determined

techniques and components originally applied when fabricating your orthotics. biomechanical

Services will make any modiication prescribed by your health care provider, at no charge, under this program. if your orthotics break, and are determined to be irrepairable, another pair will be made, at no charge, once the devices are returned to our laboratory for evaluation. repaired or replacement orthotics will be returned to your health care provider, noted above, unless other arrangements are made in advance.

LOST OR STOLEN orthotics should be reported to the prescribing practitioner. there will be a

$27.50 replacement charge per device ($55.00 per pair), to fabricate each new orthotic device.

Two devices (or one pair) may be replaced per enrollment period. Adjustment and repair beneits automatically transfer to replacement devices. your health care provider will make the necessary arrangements for any replacement orthoses.

CHILDREN seventeen (17) years of age and younger who have outgrown their orthoses may have one pair of devices replaced during the coverage period, at no charge, if they were of eligible age

at the time of enrollment. new impression molds will be required for new orthotic devices being replaced due to outgrowth, for accuracy in it of larger feet.

ORTHOTIC WARRANTY ENROLLMENT FORM

 

 

 

 

 

 

 

RETURN THIS PORTION WITH YOUR PAYMENT

 

 

 

 

orthotic number:

 

 

 

date:

 

 

 

 

name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

address

 

 

 

 

 

 

 

 

 

 

 

 

city, State, Zip

 

 

 

 

 

telephone

 

 

 

 

credit card #

 

 

exp. date

 

 

card code #

 

 

 

 

 

 

 

 

attending health care provider

 

 

 

 

name

 

 

 

 

 

 

 

 

 

 

 

 

address

 

 

 

 

 

 

 

 

 

 

 

 

city, State, Zip

 

 

 

 

telephone

 

encloSed iS my check or credit card information for payment of $60.00, pleaSe accept my completed enrollment application. enroll me in the biomechanical ServiceS extended warranty program.

Signature

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