Thank you for choosing Just Be Fit, Inc for your healthcare and physical therapy needs. Please read the following policies and complete the sections below.
FINANCIAL POLICY: Just Be Fit, Inc has contracts with many insurance plans. Due to the numerous healthcare plans available, it is the patient's responsibility to verify that we are in network with your specific insurance plan.
Insurance Benefits:
All patients are required to know their Physical Therapy benefits. As a courtesy Just Be Fit, Inc, will call to verify, however, this is not a guarantee of benefits or payment. What the company tells us can be denied or changed during and after the payment cycle. You are responsible for all denied claims. I understand that I am responsible to giving Just Be Fit, Inc any change of information with my insurance coverage. I authorize my insurer to pay any benefits for services rendered directly to Just Be Fit, Inc. I understand that anything not covered by insurance is my full responsibility.
I understand and agree that I am financially responsible for all charges for any service rendered, including late cancellation fees as described in the Treatment Guidelines within Just Be Fit Physical Therapy consent for treatment.
Initials:*
I understand and agree that while my insurance may confirm my benefits, confirmation of benefits is NOT a guarantee of payment and that I am responsible for any unpaid balance.
Initials:*
I understand and agree that it is my responsibility to know if my insurance has a deductible, co-payment, co-insurance, out-of-pocket, out-of-network, usual and customary limit, prior authorization requirements or any other type of benefit limitation for services I receive and agree to be financially responsible for all.
Initials:*
I understand and agree that if my insurance requires a referral from my primary care physician, it is my responsibility to obtain the referral. Without a referral, my insurance will not pay for any services and I will be responsible for payment.
Initials:*
I understand and agree that it is my responsibility to inform Just Be Fit, Inc. Physical Therapy in case of any changes to my insurance coverage prior to my next appointment. Claims denied due to submission to an expired insurance plan may be denied and will become my responsibility.
Initials:*
If the credit card on files changes/expires, I am responsible for informing Just Be Fit and putting an updated card on file.
Initials:*
I understand and agree, that a $25 fee for any refund checks will be charged to my account.
Initials:*
I understand and agree that if my account balance is over $300, I will be required to pay the balance in full or initiate a payment plan before additional appointments at Just Be Fit, Inc. Physical Therapy can be scheduled or before I may be seen for my next appointment.
Initials:*
I understand that unpaid balances that are more than 90 days late may be turned over to a collection agency. If my account is turned over to a collection agency, I will be responsible for an additional 33.33% of the unpaid balance to the account for the collection agency service expenses. I further agree to pay reasonable administrative fees, attorney fees, and cover cost arising out of any litigation concerning the collection of this account or any other fees deemed necessary.
Initials:*
If we contract with your plan, we will file a claim (for physical therapy services) to your insurance company. You will be responsible for any co-pays, deductibles, purchased products, and/or non-covered services. If you do not have one of the plans with which the practice is contracted, the total cost of your visit is required at the time of your service.
*It is your responsibility to provide Just Be Fit, Inc with your current insurance information. Failure to do so may result in charges being billed directly to you.
*Any service that is not covered by your insurance company, for whatever reasons, is your financial responsibility. Any outstanding balances over 90 days will be charged to your credit card. If applicable a 3% late fee will be accessed to balances over 90 days and/or patient will be sent to our collection agency.
By signing this form, I acknowledge that I understand and agree with ALL of the above, and that I accept responsibility for charges incurred for treatment or assessment at Just Be Fit, Physical Therapy, regardless of any other arrangements with third parties, including insurers. This for will remain in effect throughout the entirety of treatment with Just Be Fit, Physical Therapy until one year of signature. I agree to pay the fees outlined in this policy.
Patient/Guardian Signature:
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Signature of Person Responsible for Payment (if different from Patient):
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Just Be Fit, Physical Therapy requires that all patients keep a valid credit card on file. This information will be acquired at your first appointment. All copays, which include all non-covered services. under your insurance plan… these include but are not limit to such fees… coban wrap, tape charges, E-stim pads, heel pads or arch pads, toe pads, Iontophoresis, theraband, CLX bands, Salonpas patch, golf balls, etc....
I certify that I have been provided with the Notice of Privacy Practices and the Patient Financial Policies.
I have read and accept the policies of Just Be Fit, Inc.
I authorize Just Be Fit, Inc to charge my credit card any outstanding balances over 90 days as well as the appropriate cancelation fee if needed.
I authorize payment of medical benefits to the named provider for professional services rendered.
I authorize the release of any medical information necessary to process any claims filed.
Signature:
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