We are dedicated to providing the best possible care and service to you and regard your complete understanding of our ﬁnancial
policies as an essential element of your care and treatment. If you have any questions, please discuss them with us prior to beginning
Financial Policy, Release of Information, Assignment of Beneﬁts
Your insurance policy is a contract between you and your
insurance company. As a courtesy, we will ﬁle your
insurance claim for you if you assign the beneﬁts to us.
In other words, you agree to have your insurance
company pay us directly. If your insurance company does not
pay us within a reasonable time period, we will have to look to
you for payment of the outstanding balance.
We have made prior arrangements with many insurers and
other health plans to accept an assignment of beneﬁts. We
will bill those plans with which we have an agreement and
will only require you to pay the copayment at the time of
If you have a copay, you may either pay each time you come
for your appointment or you may pay in advance to cover all
visits for the week. Once the insurance company has begun
to process our bills, if there is a balance due, we will send
you a statement each month for the amount you owe – i.e.
deductible, coinsurance, copay, until all claims have been
processed. Payment is due upon receipt of our bill.
If you have insurance coverage with a plan with which we do
not have a prior agreement, we will prepare and send the claim
for you on an unassigned basis. This means your insurer will send
the payment directly to you. Therefore, all charges for your care
and treatment are due at the time of service.
Unless other arrangements have been made in advance by you,
or your health insurance carrier, payment for services are due at
the time of service.
All health plans are not the same and do not cover the same
services. We will do our best to determine what services
are covered by your insurance and let you know if there
is a recommended treatment that is not a beneﬁt of your
insurance so that you may decide to proceed with the
treatment or elect not to have the treatment performed.
In the event your health plan determines a service to be
“not covered” and we are unaware or you do not have
authorization, you will be responsible for the complete
You must inform our oﬃce of all insurance changes and
authorization referral requirements. In the event the oﬃce is not
informed, you will be responsible for any charges that are denied.
For all services rendered to minor patients, we will look to the
adult accompanying the patient and the parent or guardian for
Payments and Patient Signature
Past due accounts are subject to collection proceedings. All fees
including, but not limited to collection fees, attorney fees, and
court fees shall become your responsibility in addition to the
balance due this oﬃce.
Patient accounts carrying a balance longer than 30 days are subject
to a minimum monthly payment of $75 or 25% of the outstanding
balance due, whichever is larger.
There is a $50.00 service fee for all returned checks.
A $30.00 fee will be charged for all “No Shows”.
Cancellations without a 24-hour notice will be assessed a $15 Fee.
These fees are not reimbursable by insurance and are considered
due at your next visit..
I have read and understand the ﬁnancial policy of OSR
Physical Therapy and I agree to be bound by its terms. I also
understand that such terms may be amended from time to
time by this oﬃce.
I authorize the release of information necessary for treatment,
payment & health care operations.
I also authorize assignment of beneﬁts for services rendered
by OSR Physical Therapy.
Patient/Responsible Party Signature
Medical Assignment of Beneﬁts and Financial Policy
Please read this document in its entirety