PATIENT INFORMATION

    Benefits Section

    Who Carries this insurance ?

     

    HEALTH HISTORY










    Financial Responsibility

    I understand that insurance coverage is not a guarantee of payment, and that I am ultimately responsible for services rendered at REAL PT. I will honor REAL PT payment policy as stated. All co-pays and cash payment are due in full at the time of service Co-insurance and deductibles are the patients responsibility and will be invoiced once the Explanation of Benefits (EOB) is provided by the patient's insurance provider. Invoices will be due 30 days after receipt. I authorize payment of benefits directly to REAL PT for services provided. REAL PT, LLC has the right to consult a collection agency if payment is past 90 days. If any portion of the account balance exceeds 90 days the patient will be responsible for this amount plus interest of 1.5% per month, unless otherwise noted. I understand that I am financially responsible for payment of all services that are not paid by my insurance carrier. Should my account be referred to collection, I will be responsible to pay cost of collections, including legal fees.

    Consent for Treatment

    I voluntarily consent to receive treatment at REAL PT, LLC. I permit its employees and all other persons caring for me to treat me in ways they judge are beneficial to me. I understand that this care can include an evaluation, testing and treatment. No guarantees have been made to me about the outcome of this care. I hereby authorize REAL PT, LLC to release information, verbal and written, contained in my medical record, and other related information to my insurance company, rehab nurse, case manager , attorney, employer, school, related healthcare provider, assignees and/or beneficiaries, and all other related persons as it relates to my treatment and/or payment for services provided. I hereby acknowledge that I have read and received a copy of the Notice of Privacy Practices. The therapist is required by applicable federal and state law to maintain the privacy of your protected health information. We are required to give you a notice about our policy practices and your rights concerning your protected health information. We reserve the right to change our HIPAA Notice of Privacy Practices.

    Schedule and Cancellation Policy

    REAL PT will dedicate valuable and limited time and resources to satisfy your physical therapy program and schedule. Thus, you agree to provide at least 24 hours advance notice if you cannot attend a scheduled physical therapy appointment. If you do not cancel at least 24 hours prior to the scheduled start of the appointment, regardless of the reason, you are responsible for paying a $100 late cancellation fee. If you provide 24 hours advance notice, you may cancel or reschedule the appointment. All payments are non-refundable. REAL PT reserves the right to reschedule an appointment as necessary and upon reasonable notice to patient.

    Insurance Assignment

    I authorize payment directly to REAL PT, LLC for services and to bill and release payment directly to REAL PT, LLC for any Physical Therapy, strength and conditioning and rehabilitation.