273 Peninsula Farm Road

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Financial Policy and Payment Plan Agreement

 TO OUR VALUED PATIENTS:

We are committed to providing you with the best possible care.  If you have medical insurance, we are eager to help you receive your maximum allowable benefits.  In order to achieve these goals, we need your assistance, and your understanding of our payment policy.  We strongly encourage you recommend you to confirm your insurance responsibility with your medical Insurance Company. Should the information they give you regarding your coverage differ in any way please bring this to our attention immediately.

If a Deductible or Co-Insurance applies to your policy, we will send a statement for the patient responsibility after your claims have processed. You can prepay a predetermined set amount to avoid a large bill.   In the event of an over payment, after all the dates of service have been processed by your Insurance, a refund will be issued accordingly.  We will ask you to fill out the refund request form prior to payment.

Please read carefully:

  1. PAYMENTS– Copayments and payment for services are due at the beginning of EACH If a Deductible or Co-Insurance applies to your policy, the quoted cost per visit is only an estimation. When additional patient responsibility is due after your claims have processed, you will receive a statement. In the event of an over payment, after all the dates of service have been processed by your Insurance, a refund will be issued accordingly.
  2. IN NETWORK/OUT OF NETWORK-Your insurance is a contract between you, your employer and your insurance co. We are a participating provider for most insurance companies.  If we are in network, we will charge you no more than our contractual rate with your insurance company if applicable.  If we are out of network with your insurance company and your claims are submitted to your insurance company, you will be responsible for all reasonable and customary charges as indicated on the explanation of benefits received from your insurance company.  For more clarification on this, please speak with our Billing Staff.
  3. BENEFIT LIMITS– Some insurance plans have a financial or visit limit for physical therapy services. It is ultimately your responsibility to know your benefit limits.  We have procedures in place to help you stay beneath any limits, but again it is ultimately your responsibility to keep track of your limits as if you exceed your limit, you will be responsible for charges not paid by your insurance company due to the exhaustion of your benefits.   
  4. WORKERS COMPENSATION-If your injury is work related, and a Workers Compensation claim has been initiated, you must provide our office with your claim number, adjuster’s name and phone number before your initial visit. Please be advised that if your account is not paid by your comp. carrier, you will be responsible for all charges within 30 days of notification.
  5. LIABILITY CASES-For liability cases, where another party is responsible, you need to provide us with all the billing information. If you have an attorney, please provide this information on the registration form. We must You will be responsible for the account in full.