PATIENT NAME:
_______________________________
D
ATE
:
____________
ACCT
#
:
________________
Your insurance company requires NovaCare Rehabilitation to collect your co-payment amount from you at the time
of service. If we do not coll
ect these amounts we could be in violation of our contract with your insurance company
and risk being denied reimbursement for your treatment. Furthermore, we have an obligation to collect any co-
insurance % or unmet deductible amounts from you that are determined to be your responsibility.
You will receive statements from us during and after your treatment for any outstanding amounts your
insurance company indicates will be your financial responsibility. These statements will also include the amount
billed to your insurance company and the payments received from both you and your insurance company.
BILLING DISCLOSURES TO INDIVIDUALS INVOLVED IN PATIENT’S CARE
There may be times when it is necessary for an individual directly involved in your care to call the facility to
inquire about your personal health information or billing information. Please take a few moments to complete this
section.
I authorize NovaCare to disclose my health information that is directly related to my current treatment
at NovaCare to the individual(s) listed below for purposes of their role in my
treatment or payment or
payment for the health services that I have received.
Such persons involved in your care may include: spouse, children, blood relatives, roommates,
boyfriends/girlfriends, domestic partners, neighbors and colleagues.
NAME
RELATIONSHIP
I do not wish to have my health information disclosed to individuals involved in my care.
NAME
RELATIONSHIP
NovaCare Rehabilitation has verified Outpatient Physical Therapy/Occupational Therapy/Speech Therapy benefits
based on the information furnished to us
by you. Your Insurance Company has the disclaimer that this is verification
of benefits and not a guarantee of payment. Based on the information your insurance company provided to us, the
estimated amount you are responsible for is:
Co-Payment_______________
/Visit
Co-Insurance_______________ % of allowed amount
Deductible Amount Amount Not Met
Maximum Visits/Days Per Person / Condition / Year / Lifetime
Maximum Dollar Amount Out of Pocket Maximum
Other Benefit Information
NOTE: ESTIMATED coverage information is provided as a courtesy to our patients, bu
t is not intended to
release them from total responsibility of their account balance. The estimation is based on a negotiated contract
and any remaining balance due will be billed to you after additional information is received from your
insurance company.
We are committed to Service Excellence to our patients. If you have questions or concerns about your
billing, please contact our Centralized Business Office at (800)721-8202. Thank you.
NOTIFICATION of PATIENT RESPONSIBILITY for CO-PAYMENTS / CO-INSURANCE % and DEDUCTIBLES
08/01/2017
