Test Form

We bill your insurance company as a service to you. We cannot bill your insurance company unless you give us your insurance information. Your Insurance policy is a contract between you and your insurance company. We are not a party to that contract. You must supply us with a copy of your insurance card and Physician’s referral (if required). Body in Balance P.T. will not be responsible for mistakes being made due to missing or incomplete information. By signing below, you are responsible for any amount not covered by your insurance carrier and agree to pay such amounts within thirty days from the denial date. If you have no insurance, payment for services is due in full thirty (30) days from the date of service. Please be aware that some, and perhaps all, of the services provided may be non-covered services and not considered reasonable and necessary under the Medicare Program and/or any other medical insurance. If, after thirty days from the date your insurance company has paid and we have not received payment in full from you on your balance, we reserve the right to send your account to collections

All co-pays are due at the time of visit. Body in Balance P.T. reserves the right to refuse treatment to any patient not paying their co-pay at time of visit.

If payment for services not made as agreed, there will be a service charge (financecharge) of 1.5% per month, which is an annual percentage rate of 18% which could be applied to the unpaid amount. In addition, the patient or responsible party shall bear all costs of collection, including actual attorneys' fees, for any attempts at seeking amounts past due.

Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. Unless discounted rates are predetermined by the contractual agreement, you are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates.

Most Workers Compensation and Personal Injury accidents are covered 100% in our office. If you are claiming workers compensation or filing claims to a liability carrier, you must still provide us with a copy of your primary insurance card and physician’s referral. For Workers Compensation cases, we must have prior authorization from your employer to begin treatment. With Liability Cases, you must sign all forms relating to your case. Any attorney handling your case must sign our lien form. In the event payment for your claim is denied by a workers compensation or liability carrier, we will file claims with your personal health insurance. If your claim is denied and your personal health insurance will not pay for services rendered, you will be required to pay on your account t consistent with our financial policy and finance charges.

A parent of legal guardian must accompany minors at time of initial visit. The adult accompanying a minor or the parents (or guardians of the minor) is responsible for full payment. If the parents are separated and both legally responsible for treatment of their minor child, provide complete information from both parents so we may bill the appropriate insurance. The parent or guardian that accompanies the minor to our office will, be held wholly responsible for payment should any dispute over payment arise. For unaccompanied minors that are required to pay a co-pay charge, a pre-authorized approved Visa, MasterCard may be obtained or payment by cash or check at the time the service will be required.