Thank you for choosing Apex Rehab- we are committed to providing you with the best possible service and ask that you read and acknowledge the terms of our Financial Policy.

PAYMENT: All payments including copay, coinsurance and deductible are due on the date of service. We accept cash, checks, Visa, MasterCard, American Express and Discover credit cards. As a courtesy to our patients, we will contact your insurance provider to verify your physical therapy coverage. We cannot, however, guarantee the accuracy of the information we receive from your insurance provider.

COINSURANCE/DEDUCTIBLE: If you have a plan with coinsurance percentage or deductible which has not been met, we wHl estimate the coinsurance/deductible amounts based on what we have been lead to expect your insurance company will pay. Please note that any payment made on the date of service is considered a DEPOSIT toward your ESTIMATED patient balance. Because this is an estimate, there is always the possibility that you may be either responsible for an additional balance or due a refund. If a refund is due - it will be promptly provided. If it turns out that your insurance company payment is less than expected - you are responsible to promptly pay any additional balance due. An unpaid balance over 30 days past due may be referred to a collection agency. An additional collection fee of 50% of the amount owed will be added to your balance.

INSURANCE: We encourage you to call your insurance company with any specific questions related to your policy's outpatient physical therapy benefits such as deductible, copayment, coinsurance, visit limitations i.e., sharing of outpatient benefits with acupuncture, chiropractic or occupational care, effective annual calendar renewal date, or any pre-authorization requirements.

Apex Rehab cannot assume responsibility for incorrect information provided to us concerning your insurance policy. Our courtesy verification of et.gibiUty and benefits does not guarantee that your insurance company will pay for alt services provided. Your insurance policy is a contract between you and your insurance company. You are responsible tor knowing your level of coverage and are ultimately responsible for the full payment of your bill.

CANCELLATION POLICY: Therapist time is reserved for your appointment - if you are unable to keep your appointment we kindly ask that you provide us with 24-hour advance notice of cancellation. If you fail to cancel a scheduled appointment 24 hours in advance, or "no-show" an appointment, we reserve the right to assess a $50.00 cancellation fee.

By digitally signing below, I acknowledge I have read and understand the above Apex Rehab Financial Policy, agree to the terms, and understand that I am ultimately responsible for payment of the health care services provided.
Full name of patient *
Name of Guarantor (if applicable)
Never submit passwords through Google Forms.
This form was created inside of Apex Rehab LLC. Report Abuse