FIELDS IN MOTION PHYSICAL THERAPY, Inc. FINANCIAL POLICY
Welcome to Fields In Motion Physical Therapy, Inc. Everyone at Fields In Motion is committed to providing you with the best possible care throughout your course of therapy intervention. Please take a few moments to familiarize yourself with these policies. Please feel free to discuss any questions with our office staff.
Provided that you have medical insurance, we will gladly submit your insurance claims for you. In order for us to do this we require that you provide us with an opportunity to make a copy of the front and back of your insurance card and complete billing information. All patients (including worker’s compensation) are required to provide complete insurance information as well. Incomplete billing information may lead to payment delays or your claims being denied by your insurance carrier. Please also provide your physician/referral at the time of your initial visit.
The portion of your charges that are unpaid by your insurance carrier are your personal responsibility. It is your ultimate responsibility, as the patient, to see that we are paid correctly and on time, and to know your own insurance coverage. We encourage you to contact your insurance carrier directly.
IMPORTANT: Your insurance company(s) will be billed in a timely manner. A patient payment is expected at the time of service for any amount determined to be your estimated patient responsibility, i.e. percentage coverage plans, co-payments, deductibles and/or non covered charges). We accept cash, personal checks, and VISA/MC for payments. A $15.00 charge will be incurred for any returned checks.
In the event that you do not have medical insurance coverage, full payment will be expected at the time of service. We realize that temporary financial problems may affect the timely payment of your account. If this situation should occur, please contact our billing department immediately to assist you with the management of your account. There will be an 18% interest charge for any balance 90 days past due from the date of service.
If you are treated for a work related injury and the industrial carrier denies your claim, we will bill you and your individual insurance, provided we are given the correct billing information.
Our goal is to give personal and quality care and an appointment time is your reserved time. We will make every effort to see you on time and request that you be here for your reserved time. Please call us directly if you must reschedule your appointment so that we may accommodate other patients if need be. We appreciate at least a 24-hour notice of cancellation orchange of appointment. There will be a $35.00 charge for a tardy cancellation if we are unable to fill that scheduled time slot. In the event of a failed appointment (a no show), a $35.00 fee will apply. We do not bill private insurance companies, including workers compensation, for missed appointments.
I hereby instruct and direct ______insurance company to pay by check made out and mailed to: Fields In Motion Physical Therapy, Inc., 42 W. Campbell Ave., Suite 201, Campbell, CA 95008-1042
If my current policy prohibits direct payment to Fields In Motion Physical Therapy, I hereby also instruct and direct my insurance carrier referenced above to make out the check to me and mail it as follows to Fields In Motion, Inc. 42 West Campbell Avenue, Suite 201, Campbell, CA 95008-1042, for professional or medical expense benefits allowable, and otherwise payable to me under insurance policy as payment towards the total charges for the professional services rendered. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above-mentioned assignee, and I have agreed to pay, in a current manner, any balance of said professional service charges over and above this insurance payment. I also authorize the release of nay information pertinent to my case to any insurance adjuster or attorney involved in this case.
A photocopy of this Assignment shall be considered as effective and valid as the original
I understand and agree to the above the financial policy. In addition, I authorize Fields In Motion Physical Therapy, Inc. to initiate a complaint to the insurance Commissioner for any reason on my behalf.
PRINT PATIENT NAME: ______ID#(SSN): ______
______
Signature of Patient/PolicyholderSignature of Claimant, if other than policyholderDateWitness
Fields In Motion Physical Therapy, Inc.
42 West Campbell Avenue, Suite 201 ** Campbell, CA 95008-1042 ** (408) 370-2111 ** Fax (408) 370 - 2112