Please Contact Us

Email: info@orthopods.com

Telephone:

Brookline: (617) 738-8642

Cambridge (617) 491-6766

Sandwich (617) 738-8642 (call Brookline)

Waltham (781) 487-9444

Patient History Form

Patient History forms are used to help your doctor understand more about you and your health history. An accurate view of your health helps your doctor to diagnose and treat your ailments. If prescription drugs need to be prescribed, your health history and current medication list helps your doctor to choose a medication that is appropriate for you. You can come prepared by providing some background information about you, your family and medical history in this printable form: Patient History (pdf)

Insurance Information

Insurance Card: Please have this with you so we can copy all of the necessary information from it. This will
make the billing process easier for all of us. If your insurance should change, please notify the office at your
next visit.

Co-Pays: Have your payment ready when you check in at the front desk. This is a contractual obligation with
your insurance company for which you are responsible and it is mandatory that we collect it from you.

Referrals: As a member of an HMO, it is mandatory that you get a referral from your Primary Care Physician
to see a specialist and have x-rays. The Insurance Company Will Not Pay for The Visit Without a Referral
Please call your primary care physician in advance to ask for a referral. If possible, try to get a referral for
multiple visits so you do not have to repeat this process every time you come to the office. If a referral has not
been obtained and the claim is denied, you will be responsible for payment in full.
Insurance Benefits: It is your responsibility to verify benefits, know your deductible amounts, and confirm
that the doctor is a member of your plan.

If Surgery is Necessary: Please check with your insurance company to understand what costs you may
encounter. Take into considerations that there will be hospital costs as well. We will be happy to direct you to
the appropriate person in charge at the hospital. We will obtain an authorization number for your surgery, but
this does not guarantee payment.

Workers Compensation: We need to have your date of injury, claim number, and case manager’s name and
telephone number before making an appointment. If you make an appointment using your private health
insurance and inform us at the time of the appointment that it is workers comp, we reserve the right to cancel
your appointment until the claim can be verified.

Motor Vehicle Accidents: Pro Sports Orthopedics, Inc. will not bill MVAInsurance carriers or attorneys for
services rendered. All visits are to in paid in full at the time of the visit. We will assist you in obtaining pay-
ment from your insurance carrier by providing any documentation necessary.

Patient Statements: All bills are payable within 30 days of receipt. An annual interest charge of 18% will be
added to each monthly statement. After 90 days the account will be submitted to a collection agency and your
credit rating will be affected. Under the Federal Fraud and Abuse Laws, we are unable to write balances off.

Download our insurance form: Insurance Information (pdf)

These forms require the Adobe acrobat reader to view on your computer.