Our office will gladly bill all eligible insurance(s) for any date of service that you are being seen in our office and only bill you for the patient portion of you date of service based on you insurance(s) determination. You are responsible for paying your co-payment (if applicable) at each time of service. Please inform front office staff of any address, phone, insurance, insurance plan, new injury, and/or employment change to ensure accurate billing. If you are involved in third party litigation or special arrangements, please see the clinical director for further details. Patient statements are generated monthly and are due within thirty days following the date on the statement. Bills will be sent via BMS Practice Solutions, a third party billing service. *PLEASE NOTE THAT BILLING YOUR INSURANCE IS NOT A GUARANTEE OF PAYMENT. YOUR CONTRACT/PLAN IS BETWEEN YOU, THE GUARANTOR’S EMPLOYER, AND THE INSURANCE COMPANY. WE ARE NOT PARTY TO THAT CONTRACT.*
As of January 1, 2006 Medicare has implemented a dollar amount cap/visit limit for Outpatient Physical Therapy benefits. Your supplemental plan may provide coverage beyond this cap/visit limit depending on circumstances. We will work with you to keep you informed of your remaining funds under the Medicare program. This waiver is acknowledgment that you are aware of the Medicare cap and that you will be responsible for paying the balance on any visit that Medicare or your insurance does not cover.
Medical Supplies and Orthotics:
If orthotics is a covered supply by your insurance company we will bill your insurance when they are received. If your insurance denies payment for any reason you will be responsible for payment. If you do not have insurance or your insurance policy does not cover orthotics, a deposit of a minimal fee is required at the casting visit and the balance due when the orthotics are received. *ALL MEDICAL SUPPLIES NEED TO BE PAID AT TIME OF SERVICE. THESE ARE NOT COVERED BY ANY INSURANCE*
Co-pays are a contract between you and your insurance company. They are due at the time of service. We will assess a processing fee should we have to bill you for your Co-Pay responsibility.
Cancellation & No Show Policy:
If you are unable to make your scheduled appointment we ask for 24 hours notice. This provides an opportunity for another patient to schedule that appointment time. If you have an appointment on Monday we ask you cancel the appointment Friday or via voicemail/email over the weekend prior to the appointment. You will be billed a fee of $75.00 for a late cancellation/No Show. *THIS CHARGE IS NOT COVERED BY ANY INSURANCE AND IS THE PATIENTS’ RESPONSIBILITY*
Returned Check Policy:
Your account will be charged $35.00 fee for each returned check from your bank for non-sufficient funds.
Admission to our clinic is a non-discriminatory for services rendered, regardless of race, color, national origin, disability or age. All clients who come to our clinic for services are protected against discrimination assured by Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, and the Age Discrimination of 1975.
I understand that I am financially responsible for all charges for services rendered REGARDLESS OF LITIGATION, INSURANCE REIMBURSEMENT, OR PENDING LABOR & INDUSTRY CLAIM(S). I understand that the parent accompanying a minor for treatment will be responsible for payment. I authorize Peak Sports & Spine Physical Therapy to release any necessary information requested by my insurance carrier and authorize payment directly to Peak Sports & Spine Physical Therapy for any benefits available under my insurance plan. I have read and understood the above mentioned and do hereby consent to evaluation and treatment by my Physical Therapist. I also acknowledge that I have received a copy of the Notice of Privacy Practices and I have been provided an opportunity to review the notice.