Financial and Consent Form

• Consent to Physical Therapy

  Please read in entirety before you sign.

  1. CONSENT TO TREATMENT: I consent to rehabilitation and related services at Virtus Physical Therapy. In doing so, I understand, acknowledge and affirm that such rehabilitation and related services may involve bodily contact, touching, and/or direct contact of a sensitive nature.
  2. TREATMENT OF MINORS: I, as parent/guardian of a minor receiving treatment here under, do hereby agree and understand that I have been advised to remain on the premises during any such treatment, and waive any claim I may have resulting from failure to do so.
  3. LIABILITY: I know and agree that Virtus Physical Therapy is not responsible for loss or damage to personal valuables.
  4. WAIVER AND RELEASE: I hereby release, discharge and acquit Virtus Physical Therapy, it’s agents, representatives, affiliates, employees, or assigns, of and from any and all liability, claim, demand, damage, cause of action, or loss of any kind arising out of or resulting from my refusal to accept, receive or allow emergency and or medical services, including but not limited to ambulance service, Emergency Medical Technician, physician or urgent care services.
  5. AUTHORIZATION OF PAYMENT: I hereby assign all benefits directly to Virtus Physical Therapy and also authorize release of any medical records necessary to facilitate my treatment to process medical claims and as otherwise permitted or required in the Notice of Privacy Practices. I understand fully that in the event my insurance company or financially responsible party does not pay for the services I receive, I will be financially responsible for payment.

  I certify that all of the information provided herein is true and correct.

  I Agree

• Financial Policy

  Thank you for choosing Virtus Physical Therapy as your Physical Therapy provider. We are committed to providing the best possible care for you. In order to achieve this goal, we need your assistance in understanding our payment policy. Please understand that payment of your bills is considered part of your treatment. The following is a statement of our Financial Policy. Please read and sign prior to your treatment.

  Payment of services is due prior or upon completion of each treatment visit. We accept CASH, MASTERCARD, VISA, DISCOVER, or PERSONAL CHECKS. Once your complete insurance information is on file, we will be happy to submit your claims to your insurance company.

  I Agree

• Private Insurance

  We will gladly discuss your proposed treatment and answer any questions relating to your insurance. You must realize, however, that your insurance is a contract between you, your employer, and the insurance company. We are not party to that contract. We must emphasize that as your provider, our relationship is with you, and not your insurance company. While the filing of insurance claims is a courtesy we extend to our patients, all charges are your responsibility from the date of services rendered.

  It is our policy to call and verify benefits and eligibility to estimate your payment portion. However, there is no guarantee from the insurance company of their payment amount. We may not know the exact amount due until the claim has been processed. At this point, there may be more due on your account. In this event, we will mail you a statement, and appreciate your prompt payment.

  Regarding insurance plans where we are a participating provider, we will take the contracted rate assigned by the insurance company and make the proper adjustments to your claim.

  I Agree

• Non Covered Expenses

  Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You may be responsible for payment of charges denied due to the insurance company’s arbitrary determination of usual and customary rates. There may also be charges that your insurance does not cover due to limitations of your policy, or what they consider reasonable and necessary. It is your responsibility to know what the policy limitations are. Our goal is to improve your condition successfully based on what the doctor deems reasonable and necessary treatment, and not on what your policy limitations are. Therefore, unless you alert us prior to treatment, you will be financially responsible for non-covered expenses.

  I Agree

• Cancellation and No Shows

  Please be on time for your appointments so that you may be given the full benefit of your scheduled treatment. Late arrival of greater than 15 minutes may result in a shortened treatment or cancellation. It is our policy to try to accommodate to reschedule any canceled appointments for the same week at the time of your call. Attending your scheduled appointments is crucial to successful treatment and recovery from your injury. It is our policy that three (3) consecutive cancellations and no shows will result in termination of physical therapy services.

  I Agree

• Signature

  I agree that the signature and initials will be the electronic representation of my signature and initials for all purposes when I use them on documents for Virtus Physical Therapy—just the same as pen-and-paper signature and initial.
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