In order to maintain the highest quality of service as well as to continue progressing with the established plan to help reach your goals we ask that you show us consideration with the following:

- Cancellation within 24 hours or a failure to arrive at your scheduled appointment will be billed at the cost of a standard session of care. Cancelling/Rescheduling appointments can be done by reaching out directly to your therapist that you scheduled with via phone or e-mail.

- Late Starting Appointments: I understand that if I am late, the session will conclude at the scheduled time to show consideration for other clients scheduled following.

We ask that a credit card be stored on file to allow for this policy to be maintained. If you refuse to have a credit card on file, payment for late cancels and no-show appointments will be invoiced to be paid within 7 days or additional fees will be added. The provider reserves the right to waive charging fees for extraneous circumstances. This policy applies to all clients of Results Rehab Physical Therapy regardless of coverage by insurance or third party payor.

I give my consent to Results Rehab Physical Therapy to furnish care and treatment that is considered necessary and proper in the diagnosing and/or treatment of my physical condition. I understand that I will maintain bodily autonomy at all times and have full control over further treatments that will be discussed with my therapist. If Trigger Point Dry Needling is agreed upon with my provider, I give permission based on the expertise and education of my provider and understand and accept the risks associated with its use.

Results Rehab Physical Therapy is committed to excellence in care and transparency in billing. Results Rehab will bill on the behalf of the client for standard Medicare part B, and auto accidents in partnership with certain attorneys. We are considered a Fee-for-Service and Out-of-Network clinic for all other insurances. This means that payment is due in full at the time services are rendered and we will only bill In-Network (Medicare Part B) insurance companies. Otherwise, we can, upon request, provide receipts with diagnosis and treatment codes which you may choose to submit to your insurance company for any potential reimbursement . If further reports or documentation are requested, these will be provided.

Out-of-Pocket Rates:

Single visit: $245/visit

Mobile package: $225/visit

Membership (gym package): $205/visit

At my (client’s) discretion, Results Rehab can split package into 2 or 3 installments upon request, with understanding that I (the client) am still committing to paying the full package price

We accept cash, personal checks, and all major credit cards as well as HSA/FSA cards. Cards will be saved on file for ease of future payments. Please let Results Rehab know if you would not like your card kept on file. I understand my responsibility in providing accurate information for billing in these situations and recognize my responsibility to pay if payment is not provided by and through insurance. All other clients are expected to pay at or before the time of service or have an established payment plan.

RESPONSIBILITY FOR PAYMENT: All deductibles are due at the time of service. I acknowledge that in consideration of the services provided to me by Results Rehab, LLC, I am financially responsible for payment of my bill. I acknowledge that it is my responsibility to provide Results Rehab, LLC with current insurance information and to familiarize myself with my insurance plan and its policies. Any questions I have regarding my health insurance coverage or benefit levels should be directed to my health plan. My health insurance plan may provide that a portion of the charges and balance will remain my personal responsibility, such as my deductible, co-payment, co-insurance or charges not covered or denied by my health insurance, Medicare, or other programs for which I am eligible. Please note that refusal to sign this form does not change responsibility for payment in any way.

4. ASSIGNMENT OF BENEFITS: I hereby assign to Results Rehab, LLC, all my rights and claims for reimbursement under my health insurance policy. I agree to provide information as needed to establish my eligibility for such benefits.

If Medicare doesn’t pay for Physical Therapy below, you may have to pay.

Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the Physical Therapy below:

Uncovered Services: Dry Needling, Wellness, Nutrition Education, Equipment Fitting/Education, Comprehensive and Personalized Home Exercise Program, Home Assessment)

$80/session (in-clinic)

$100/session (in-home)

This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048).