Our Financial And Privacy Policy

 

We are committed to providing you with the best possible medical care. If you have medical insurance, we will try to help you receive your maximum allowable benefits. Please carefully read the following, and complete the enclosed forms.

 

PAYMENT FOR SERVICES is due at the time services are rendered or upon receipt of patient billing statement. In order to expedite this payment we accept cash, personal checks and accept MASTERCARD or VISA.

 

We will do our best to verify that we can treat you. This is however, no guaranty of benefit. Any questions requiring your policy deductibles and co-pay refer to your insurance company.

 

         INSURANCE: For many of you, your insurance is a contract between you and your employer or an insurance company, and we are not a party to that contract. For some of you, we are under contract with your employer or insurance company. For those patients whose plans list or accept Mitchell Physical Therapy, Inc. as a contract provider, we will submit the appropriate claim to your carrier. AFTER our office has received payment from your insurance company and all appropriate adjustments have been made, YOUR remaining balance will be billed to you and is then due and payable upon receipt of the bill. Be advised our services may be Out of Network for your policy, which could result in you having to meet an additional deductible.

         MEDICARE: For those patients who are covered by Medicare, we will comply PATIENTS: with the law requiring physiciansí offices to process insurance forms. AFTER our office has received payment from your insurance company and all appropriate adjustment have been made, YOUR remaining balance will be billed to you and is then due and payable upon receipt of the bill.

         WORK COMP: Mitchell Physical Therapy, Inc. will submit the appropriate claim to your carrier. If your claim is denied you will be responsible for the entire balance. Your bill in then due and payable upon receipt.

         AUTO CLAIMS: Mitchell Physical Therapy, Inc. will submit the appropriate claim to your carrier. If your claim is denied you will be responsible for the entire balance. If your PIP runs out or your claim goes to litigation you will be responsible for the balance. We will not carry the balance until your settlement, as we are not a party to your claim.

         RETURNED CHECKS: There is a $25 fee for all returned checks.

         PAYMENT PLANS: If you believe you will need a payment plan, arrangements will need to be approved through our billing department PRIOR to your balance exceeding $100 and are subject to approval.

         BE ADVISED A $3.00 REBILL FEE WILL BE APPLIED TO DELAYED PAYMENTS

         If questions arise, please contact our billing department at 1-888-467-2425 for assistance. We consider financial matters and protection of your medical information important and ask you to bring any concerns to our attention

         PROTECTION OF PATIENT INFORMATION: Please understand your patient information is held in confidences and that no information will be given out without your direct consent. By signing this form it gives us permission to use your information solely for the purpose of collection of your claims. If information is requested by anyone or company other than your insurance or yourself, you will need to provide us with a release of information approval form. Copies of this policy are posted in the clinic and are also available for your records.

 

Thank you for using Mitchell Physical Therapy, Inc. for your care.

 

 

I have read and understand this financial and privacy policy.††††††††††††††† Signature:†††††††††††††††††††††††††††† ††††††††††††††† ††††††††††† †††Date:††††††††††††††††††††††