Vail Physical Therapy

Financial Policy

We emphasize that, as healthcare providers, our relationship is with you, not your insurance company. Verification of your insurance benefits does not guarantee payment by your insurance company, and is not a guarantee of coverage. As a courtesy, we will verify your primary insurance carrier on your behalf, however the information we attain is only what the insurer states to us. You are responsible for understanding any and all limitations on your insurance policy, including but not limited to: visit limits and monetary benefit capitation on amounts paid. We encourage you to call your primary and secondary insurance providers prior to receiving physical therapy services so you have the most current and detailed information regarding your benefits and your specific financial responsibility.

The physical therapy services you have elected to receive imply a financial responsibility on your part. This responsibility obligates you to ensure payment of our fees in full after submission to insurance. We will bill your insurance company providing you give us an accurate, legible copy of your current insurance card (both sides) at your first appointment, and notify Vail Physical Therapy, LLC of any changes to your insurance plan during your duration of treatment. We do not take responsibility for any denial of claims by your insurance company, including but not limited to: denials due to lack of authorization, pre-authorization, limitations on your insurance policy, or because of any delays in receiving your health insurance information.

I hereby guarantee payment of physical therapy expenses while at Vail Physical Therapy, LLC.

I am the patient/parent or legal guardian for the noted patient and accept legal responsibility for all expenses. I understand that I am financially responsible to Vail Physical Therapy, LLC for any and all expenses incurred, including those not covered by or paid for by my insurance company. I also understand that I am financially responsible if a problem develops with my insurance carrier and payment is not made within 60 days. Should my account become delinquent, I understand that I will be responsible for any and all collection/attorney/filing fees incurred in trying to collect payment. I verify that the given information to Vail Physical Therapy is current and accurate. I have read and agree to the statement above and I am seeking treatment voluntarily. My signature authorizes payment of any insurance benefits to the supplier of services (I assign any and all benefits directly to Vail Physical Therapy, LLC.).

Vail Physical Therapy asks for and reserves the right to charge:

• $50.00 for appointments not canceled with at least 24-hour notice

• All outstanding statement balances when unpaid 30 days post issued statement

• Co-payment/co-insurance at the time of service, as determined by your insurance carrier.

I have read the above policy regarding my financial responsibility to Vail Physical Therapy and I authorize my insurer to be billed for my services. I authorize Vail Physical Therapy, LLC to hold my credit card information on file in a secure location (InstaMed) and assume responsibility for any remaining balance, regardless of reason and permit this amount to be charged to my card on file.

I have reviewed the Good Faith Estimate: Physical Therapy: $120-$220/session.