Orem Sports Medicine Center
Bushnell Physical Therapy
Insurance Policy
Bushnell Physical Therapy will bill insurance companies as a courtesy to our patients. It is the patient/responsible party’s responsibility to make sure that our office has the most accurate insurance information on file at your time of service. If policy changes, it is the responsibility of the patient to notify our office.If we do not have accurate information, charges may become the responsibility of the patient. Bushnell Physical Therapy, as a courtesy, will call your insurance at your initial appointment and receive your Physical Therapy benefits, however, this is not a guarantee of payment and it is the patient’s responsibility to know and understand their benefits. Be aware that each insurance company has different plans with different deductibles, co-pays, and benefits and actual benefits may differ from any estimates you may receive. After your insurance has processed your claims, you will be responsible for the remaining balance left by your insurance. Copays are due at the time of service.
If you do not have medical insurance, we offer a self-pay rate for services which is due at the time of service and no insurance will be billed.
I have read and received a copy of the clinic polices.
I have given or emailed the front office the most recent copy of my insurance cards including primary and secondary insurances.
I have not given the front office a copy of my insurance cards but have written it below.
I do not have health insurance.
My Injury is Work Related (please fill out accident form)
My Injury is Auto Related (please fill out accident form)
I am currently or will be working with a lawyer (please see lien)
Lawyer Name: ______Phone #: (____)______
Insurance Information
Primary Insurance Carrier: ______Phone #: (____)______
Group #: ______Policy #: ______Insured Name:______Gender:M F Social Security #:______Date of Birth: ___/____/____
Relationship to Patient: ______Phone #: (____)______
Insured Employer: ______Work Phone # (____)______
______
All fees for medical care are due and payable upon completion of treatment, unless prior arrangements have been made IN WRITING. A billing fee will be charged at a rate of 1.75% per month (APR 21%) or $5.00 per month on balances 30 days past due of last date of service. In the event that any balance is not paid as agreed upon, the undersigned agrees to pay the balance and all collection charges incurred, including collection (at 50%) and reasonable attorney fees. I understand that it is my responsibility to understand and know my insurance benefits and that it is a courtesy of Orem Sports Medicine Center to call on benefits.
Assignment of benefits and release of information: I hereby request and authorize my insurance company to pay my insurance benefit payments directly to the provider. I understand that my insurance coverage is a contract between the insurance company and me and not between the insurance company and the provider. The provider will bill the insurance company as a courtesy. In the case that my insurance company does not pay the balance in full the remaining balance will be due and payable immediately by me.
Patient/Parent/Guardian Signature: ______Date: ______
I authorize ______(Name and Relationship) to discuss my finances and treatment.