Patient Insurance Assignment Form

Patient Insurance Assignment Form

Please note, this form is secure but it is not HIPAA-compliant. If you would rather print and bring this form with you to the appointment, click here.

Thank you for choosing Physical Therapy Evolution. We will work with you and with your insurance carrier to submit claims, but would like you to understand our office policy regarding insurance assignment. Payment is expected at the time of service unless previous payment arrangements have been made. For our office to accept insurance assignment, we ask that you read and sign the following.

You acknowledge that it is your responsibility to:

➢ Provide complete, current information of medical insurance coverage for yourself (or the patient if under 18), including providing a valid insurance card (or cards) and photo ID at the time of service.

➢ Pay applicable co-payment or co-insurance at the time of service, if applicable. A minimum per-visit charge may be asked for high deductibles that have not yet been met.

➢ Present a valid referral or authorization number for all services (if required by your insurance company). Your primary care physician or referring specialist can help if needed.

➢ Inform us if the patient’s need for medical services is due to a motor vehicle, worker’s compensation, or other accident.

➢ Make payment within 30 days on any balance on your account for amounts due such as deductibles, coinsurance, co-payments or non-covered services.

➢ Verify that Physical Therapy Evolution is in-network with your insurance plan under your insurance carrier.

➢ You are ultimately responsible to pay the medical bill if your insurance company does not honor the assignment of benefits in whole or in part.

Your signature below indicates:

1. You understand and accept our policy of assignment of insurance benefits.

2. You attest to the accuracy/completeness of the medical insurance coverage information.

3. You authorize this office to release medical information necessary to process your claims and appeals.

4. You authorize payment of medical benefits to Physical Therapy Evolution.

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