Thank you for choosing us as your health care provider. This document is a summary of our financial policies, an explanation of your responsibilities, and authorization to bill your insurance on your behalf for services rendered. You may be responsible for co-pays, deductibles, and services provided which may not be considered a benefit under your policy. Your insurance may deny claims for a variety of reasons
1. The services provided may not be a benefit of your insurance policy or may not be covered when provided by our office (such as Physiotherapy modalities, heat, massage, traction, exercise instruction, nutritional advice and or supplements.)
2. You may have exhausted the benefits of the services provided. Medical Necessity or Medically Necessary generally means a determination based upon criteria and guidelines developed by your insurance carrier in consideration of generally accepted standards and practices. Their services must meet all of the following criteria:
a. It is generally accepted as necessary and appropriate for the patient’s condition, given the symptoms, and is consistent with the diagnosis and;
b. It is essential or relevant to the evaluation or treatment of the injury, condition, or illness and is not mainly for the convenience of the member of the Physician and it is reasonably excepted to improve the patient’s condition or level of function or, in the case of diagnostic testing, the results are used in the diagnosis and /or management of the patient’s care.
Patients/Responsible Party Agreement (please place your initials next to each statement) |