Test Form

Contact Form for Body in Balance

Financial Policy Form

  • Thank you for choosing us as your Physical Therapy provider. The following is a statement of our Financial Policy, which we require you to read, check agreement boxes and sign prior to receiving any treatment.

    CO-PAYS THAT ARE REQUIRED BY YOUR INSURANCE POLICY ARE DUE AT TIME OF SERVICE.

  • MM slash DD slash YYYY
  • If you have insurance, balances will be considered current from the date your insurance pays its portion. You will have a thirty-day grace period to pay your portion of the services. There will be a $20.00 service charge for all returned checks.
    I have read the financial policy. I understand and agree to this Financial Policy:
  • MM slash DD slash YYYY
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