I, the undersigned, certify that I (or my dependent) have insurance coverage with the named insurance on the patient registration form and assign directly to Agapé Physical Therapy all insurance benefits, if any, otherwise payable to me for services rendered.
Agapé Physiscal Therapy has a 24-hour cancellation policy.
Co-Payments are due at the beginning of service and not considered billable.
A $15 fee will be charged to your account for every time a "No-Show" occurs. Also, a $15 fee will be charged to your account when you do not cancel and reschedule within the 24-hour cancellation policy.
We understand that there are circumstances where this is not possible and the Agapé staff will determine on a case by case basis.
Any returned check for insufficient funds will be charged a $10 bank fee.
Co-payments and Deductibles are contractual agreements between you and your insurance company. If your contract has a deductible amount, we ask that you pay towards your deductible each visit. If you are responsible for a co-insurance, the Agapé staff can figure out this amount for you and you can make this payment at each visit. You will be billed for any remaining balance once your insurance company processes the claims. In the event that you overpay, Agapé will reimburse you the difference once your insurance carrier has processed and paid all of your claims.
We participate in a number of insurance plans to whom we will submit a claim on your behalf for covered services and bill you for any remaining balances. Balances are due within 30 days and are considered past due after that.
If your insurance carrier refuses to pay for services rendered and your deductible has not been met, or you classify as self-pay, you will be required to pay Agapé Physical Therapy all applicable costs for services rendered. In the event of non-payment, your account will be assigned to collections and shall be liable for the charges paid to the collection agency.
I hereby verify that I have read and understand the above financial policy. I authorize Agapé Physical Therapy to release all information necessary to secure the payment of benefits and to use this signature on all insurance submissions.