New patient forms

Financial Policy

Billing, balances and our 24-hour cancellation policy — please review and acknowledge before your first visit.

Paying for your medical care

Thank you for giving us the opportunity to work with you. We're happy to provide a billing office to submit all insurance claims for you.

Financial policy

Know your plan

Please understand your insurance plan, including benefits, co-payments and deductibles. You are responsible for contacting your insurance plan before therapy to identify what level of coverage you can expect. Non-covered services, denied bills or slow payments by an insurance company will be billed directly to you.

I understand I will be responsible for any balance not covered by my insurance carrier.

Balances

Orenstein Physical Therapy reserves the right to suspend treatment if your outstanding balance exceeds $600.00 for more than 30 days, or if your balance is outstanding for more than 90 days. Unpaid patient balances 60 days and older are assessed a service charge at a monthly rate of 1.5%. Bills over 90 days old accrue interest at 1.5% per month. If an account is sent to a collection agency, their 28% fee will be added to the account balance.

I have read and recognize these financial policies.

For clarification about billing and statements, contact Annette Elizabeth at A.C.E. Billing, 952.922.9121.

Required information

1. Records release & assignment of benefits

A signed Records Release / Assignment of Benefits (included on the Patient Information form).

2. Auto accident claims

We require the name, address and telephone number of your employer and insurance carrier, the date and cause of injury, and the claim number — plus your private health insurance information should your claim be denied or benefits exhausted.

If you choose not to provide the above information, you will be held personally responsible for payment. Providing it frees you to concentrate on getting well and lets us work on your behalf to secure your maximum insurance benefits. Your medical policy is a contract between you and your insurance carrier; ultimately, payment for your care is your responsibility.

Cancellation notice policy

24 hours' notice

Please notify our office of cancellation no later than 24 hours prior to your scheduled appointment. Failure to do so will result in a $181.50 service charge billed directly to you, to be paid prior to your next scheduled visit. Subsequent late (or failed) cancellations will be subject to a $181.50 charge and the suspension or termination of further treatment.

I have read and understand the cancellation notice policy.

Acknowledgement

“I acknowledge that I have read, understand and accept the above financial policy.”

Patient signature (type full name)

Printed name

Date

Your information is confidential. Questions about billing? Call A.C.E. Billing at 952.922.9121.