I hereby assign payment for services rendered to me (or my dependent). I authorize to disclose all or any part of my (or my dependent's) record to my physician and any person or corporation which may be liable for all or any part of the charges including but not limited to insurance companies, Worker's Compensation carriers, or employers.

We will contact your insurance company in regards to coverage for physical therapy so that we may bill them directly. Please be aware that you may be responsible for a deductible, co-insurance, and/or co-pay depending on your coverage. It is the patient's responsibility to know what their insurance does or does not cover. Payment of the bill is the patient's responsibility. Payment in lull is expected within 90 days or completion of care. Those accounts not paid in full after 90 days are subject to interest charges and placement with a collection agency.

PATIENT INFORMATION FORM - MOUNT LEBANON

INSURANCE INFORMATION

INSURANCE INFORMATION

By checking the following boxes and signing at the bottom of the form, I hereby consent to the following:

By checking the following boxes and signing at the bottom of the form, I hereby consent to the following:

HABILITY OPT-IN SHEET

HABILITY OPT-IN SHEET

Great news patients!

We have recently acquired a new system that allows you to contact your Physical Therapist as needed by either phone, email or text. We will not contact you regarding your billing, co-pays or such issues through email or text.

This service is to make sure if you have questions regarding your care, that they can be addressed as soon as possible. Selections can be changed at any time, too. Simply select your preferred method of contact below, initial next to it, and we'll handle the rest for you!

Talk soon!