Middleton Physical Therapy Patient Intake Form
By filling out the below form you are agreeing to the following Patient Financial Agreement Terms:
—– Patient Financial Agreement —–
Thank you for choosing Peak Physical Therapy. We are committed to providing you with the best possible physical therapy care.
PAYMENT: Timely payment of your bill is an essential part of your treatment. The patient or responsible party will be responsible for all copay, deductible and coinsurance amounts. Copays are due at the time services are rendered. Payment agreements will be accepted for deductible and coinsurance amounts. Payment agreements will remain consistent as agreed upon per your signed agreement until this agreement reaches default. At this point, we retain the right to adjust the payment amount. Our office accepts cash, checks and Visa/MasterCard/Discover/American Express credit and debit cards.
As a courtesy to our patients, we will contact your insurance provider to verify your physical therapy coverage and benefits. We cannot guarantee the accuracy of the information we receive from your insurance provider.
INSURANCE: We encourage you to call your insurance company with any specific questions related to your policy’s outpatient physical therapy benefits such as deductible, copayment, coinsurance, visit limitations, effective annual calendar renewal date, or any pre-authorization requirements. We do not accept any 3rd party motor vehicle insurance carriers. Insurance carriers must belong to the patient or responsible party.
COINSURANCE/DEDUCTIBLE: We will make every attempt to obtain payment from your insurance. Any payments toward your coinsurance or deductible are considered a DEPOSIT toward your ESTIMATED patient balance. We encourage you to check all explanations of benefits provided by your insurance to determine what is owed. An unpaid balance over 30 days or failure to make payments as agreed upon in a payment plan may be referred to a collection agency.
COPAYMENT: Due at the time of service.
Peak Physical Therapy cannot assume responsibility for incorrect information provided to us concerning your insurance policy. Our courtesy verification of eligibility and benefits does not guarantee that your insurance company will pay for all services provided. Your insurance policy is a contract between you and your insurance company. You are responsible for knowing your level of coverage and are ultimately responsible for the full payment of your bill.
THERAPY SUPPLIES: Any supply or durable medical equipment provided to you will exclusively be your financial responsibility and will need to be paid at the time of service and/or upon receiving the supply. An Advanced Beneficiary Notice (ABN) form and authorization to bill your insurance must be obtained before supplies are billed.
PATIENT FINANCIAL AGREEMENT
Benefit Assignment/Release of Information: Upon Patient or Responsible Party signature, Peak Physical Therapy is authorized to bill insurance companies provided by the patient and or responsible party for all services rendered by its contracting providers. I agree to forward all insurance payments paid to me directly to Peak Physical Therapy. I hereby authorize Peak Physical Therapy to release all information necessary, including medical records, to secure payment.
Consent of Treatment of a Minor: As a parent and/or legal guardian, I authorize Peak Physical Therapy to treat the minor named in the intake documents while I am not present.
Workers’ Compensation Claims: If I claim Workers’ Compensation benefits and am subsequently denied such benefits, I will be held responsible for the total amount of charges for services rendered
No-Show/Cancellation Policy: All patients who do not cancel their appointment within 24-hours or more of their scheduled appointment will be charged $20.00 at their next appointment. Patients who do not show up to their appointment and do not call to cancel will receive a $25.00 “No-Show” fee. These fees can be waived for patients who re-schedule their appointment within that week.
Consent to treatment: I consent to receive outpatient rehabilitation therapy services and any ancillary services that are deemed medically necessary or appropriate by my physical therapist and/or treating physician. However, I am aware that the practice of rehabilitation therapy is not an exact discipline and I acknowledge that no guarantees have been made to me regarding treatment.
HIPAA: I hereby acknowledge that I have received a copy of Peak Physical Therapy Notice of Privacy Practices on this day.