Physical Therapy Financial Policy and Payment Agreement

Patient Information

Name: _________________________ Date: _____________ Date of Birth: __________________ Account #: _________

Financial Policy Terms

Insurance Coverage

• I understand that it is my responsibility to verify my insurance coverage for physical therapy services
• I acknowledge that any quotes of benefits received from my insurance company are not a guarantee of payment
• I agree to inform the clinic of any changes in my insurance coverage immediately

Patient Financial Responsibility

1. Co-payments and Deductibles

   • All co-payments are due at the time of service
   • I understand I am responsible for meeting my annual deductible
   • Any outstanding deductible amounts will be collected at the time of service

2. Non-covered Services

   • I understand that some services may not be covered by my insurance
   • I agree to pay for any services denied as non-covered by my insurance
   • Payment for non-covered services is due at the time of service

Cancellation and No-show Policy

• 24-hour notice is required for cancellation of appointments
• A fee of $_____ will be charged for no-shows or late cancellations
• Repeated no-shows may result in discharge from therapy

Payment Methods

• We accept cash, personal checks, and major credit cards
• Payment plans may be available upon request and approval
• Returned checks will incur a fee of $_____

Agreement

I have read and understand the financial policy above. I agree to comply with these terms and accept financial responsibility for all physical therapy services rendered.

Signature: _________________________ Date: _____________

Print Name: ________________________

Office Use Only

Received by: ________________________ Date: _____________