Reference Forms_ Billing and Cancellation Policy.pdf

Let’s Get Physical Therapy

35840 Chester Road Suite F

Avon, Ohio 44011

Phone: 440-937-5210

Fax: 440-937-5212

www.letsgetpt.com

Billing and Cancellation Policy

Cancellation: We ask that you give 24 hours prior to canceling or changing an appointment. If you do

not give 24 hours notice or if you no show for an appointment, a $50 charge will be placed on your

bill. Severe weather is not a cause for the fee. Three consecutive cancellations or no shows will result in

our office canceling all remaining appointments.

Notice of Privacy Practice: The full Policy is available upon your request. We conform to the

guidelines set in 2004 by our Government, and do not share Medical Private Health Information with

anyone other than your doctor. If there is another person you wish to receive information -- i.e. spouse or

other family member -- write their name or names below.

____________________________________________________________________________________

Authorization & Consent: I authorize Assignment of Benefits, which means that I agree to allow

release of all needed medical information to my insurance company in order to have my bill paid. This

may include, but is not limited to medical coding and documentation. I authorize the payment the

payment for services I receive to be assigned to ‘Let’s Get Physical’ Therapy Group. I also understand

that I am responsible for all unpaid balances that go to my deductible, co-insurance, or are co-payments

for services I receive. ‘Let’s Get Physical’ Therapy will file the Claim on my behalf and payment will be

sent directly to their office. I will be informed of all charges that are expected to be non-covered services

by my provider in advance.

Consent: I understand that I am to receive Physical Therapy evaluation and treatment at this office, and

I hereby consent to these treatments performed by a Physical Therapist or a Physical Therapist Assistant

as is best practice and standard for my diagnosis and or injury. This consent is a waiver of liability for

these treatments, with the exception of acts of negligence.

_________________________________________ _______________________________

Signature: Date:

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Witness/Staff Signature: