Financial Agreement - Progressive Physical Therapy

Financial Agreement Medical Records Release Privacy Policy

Check Each Box And Enter Your Initials For All That Apply.

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Please be advised that you will remain financially responsible for services rendered regardless of the payment option selected below. In the event your account becomes delinquent and is, therefore, in default of payment, the patient, or admitting legal guardian, will be responsible for the principal amount owed, along with all reasonable costs associated with the collection of this debt, including, but not limited to, collection service fees, attorney’s fees, all court costs, and all additional legal expenses associated with the recovery of this debt. We reserve the right to charge interest on balances over 30 days old, and charge returned check fees as allowed by Arizona state law. After 90 days, all unpaid balances will be assessed a 1.5% monthly interest rate.

Who will Progressive Physical Therapy be billing? *

Health Insurance
Self-Pay
Worker’s Compsensation
Claims-Auto or Personal Injury
VA

Please Select Your Health Insurance *

Medicare
Primary Insurance (BCBS, UHC, Aetna, Cigna, VA, Tricare, TriWest, Advantage Plans, )

Primary Insurance – Your primary insurance will be billed as a courtesy to you. Co-pays are due at time of service unless other arrangements have been made with the office. Upon beginning therapy, all effort will be employed to verify insurance benefits as an additional courtesy. <em>While we commit to taking all reasonable action to provide accurate benefit information for your specific plan, be aware that verification of benefits is not a guarantee of payment from your insurance carrier. Patient is responsible for understanding personal coverage benefits and limitations. Patient is accountable for all charges incurred during treatment after 90 days if not covered by insurance.</em> *

VA – TriWest PCS – The VA will be billed as a courtesy to you. Co-pays are due at time of service unless other arrangements have been made with the office. Upon beginning therapy, all effort will be employed to verify insurance benefits as an additional courtesy. While we commit to taking all reasonable action to provide accurate benefit information for your specific plan, be aware that verification of benefits is not a guarantee of payment from your insurance carrier. Patient is responsible for understanding personal coverage benefits and limitations. Patient is accountable for all charges incurred during treatment after 90 days if not covered by insurance. *

Medicare – For your convenience we will bill Medicare for you. In most cases, Medicare will pay 80% of allowable charges when “medical necessity” requirements are met. Medicare or our office will bill your secondary insurance. If no secondary insurance is provided, the 20% balance will be billed to you. Please read below for additional information. *

MEDICARE PHYSICAL THERAPY BENEFITS

Medicare has placed a THRESHOLD or “limit” of $2410.00 on all Physical Therapy & Speech Therapy charges combined. 2025 Medicare deductible is $257.00.

Medicare benefits will cover up to $2410.00 of “medically necessary” Physical Therapy for each participant per calendar year. Medical necessity is determined by your Physical Therapist following Medicare established requirements. Each individual Physical Therapy appointment, a Medicare allowed charge (determined by Medicare) is assigned based on the services you received. If you have not met your deductible ($257.00 for 2025), you will be required to pay the allowed charge for your visits until you meet the deductible. Once your deductible is met, Medicare will pay 80% of the allowed charges and secondary insurance and/or patient will be responsible for the remaining 20%. In both of these cases, collected payment is subtracted from your allotted $2410.00 Physical Therapy benefits until they are exhausted for the calendar year. Please be advised that Medicare deductible and allotted Physical Therapy benefits are renewed January 1 of each year.

Please consult Medicare directly with any benefit inquires.

Medicare contact number: 1-800-MEDICARE

Self-Pay. $125 Evaluation (1st Visit) $90 for each Follow-Up Visit *

Please pay balance in full at time of service. Refunds and retro billing are not available.

Good Faith Estimate for Physical Therapy Services. Federal law, under the No Surprise Act, requires health care facilities provide an estimate of total cost of services to patients who do not have insurance or are paying cash for treatment. This Good Faith Estimate shows the costs of services that are reasonably expected for your health care needs for Physical Therapy. The estimate is based on the information known at the time the estimate was created. This estimate is based on an average of 8 treatment sessions. Please note that your individual treatment may require less than 8 appointments, reducing the cost. Patient will only be charged for prior arranged and accepted scheduled appointments. Good Faith Estimate is for $755 -1 evaluation appointment at $125 + 7 follow-up appointments at $90/each. If only 3 appointments are required patient will be charged $305 -1 evaluation and 2 standard appointments, etc. The Good Faith Estimates does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens (this is not expected here at Progressive Physical Therapy), federal law allows you to dispute (appeal) the bill. At Progressive Physical Therapy you may accumulate additional charges ONLY if further appointments are required for optimal treatment, or a rare circumstance requiring you receive an evaluation appointment rather than a standard visit- due to complex status change or a new region of injury discovery. Patient is responsible for scheduling additional appointments; appointments and cost will not be incurred without patient knowledge and acceptance. This Good Faith Estimate is not a contract and does not require the patient to obtain the services from any of the providers or facility identified with in. Treatment may be discontinued at any time by either the patient or rendering Physical Therapist. If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill. You may contact the health care provider or facility (Progressive Physical Therapy) listed to let them know the billed charges are higher than the Good Faith Estimate. You may ask them to update the bill to match the estimate, ask to negotiate the bill, or ask if there is financial assistance available. For questions or more information about your right to a Good Faith Estimate, visit http://www.cms.gov/nosurprises or call 1-800-985-3059. By signing you affirm you underestand the cost of physical therapy servies provided by Proressive Physical Therapy.Address: 155 W. Duval Rd. Green Valley, AZ 85614 NPI: 1215995493 TIN: 202768176 Phone: 520 648 3132. Contact: Marie Olsen, Clinic Administrator. Each individual appointment Paid at visit check in. Please let the front office know if you would like a copy of the Good Faith Estimate. *

Good Faith Estimate Diagnosis and Diagnosis Code: *

Example: Lower Back Pain – M54.5 If you don’t know the ICD-10 diagnosis code, you may provide the body part we are treating.

Date Good Faith Estimate was signed. The Good Faith Estimate will be valid for 1 YEAR from the date provided below. *

Worker's Compensation – A valid claim/case number, adjuster contact, and billing address must be provided in order for your Worker’s Compensation carrier to be billed for your treatment. Per contract, all attendance records will be forwarded to claims adjuster. Please note patient will remain financially responsible for all charges if carrier denies coverage for any reason. *

Claims – Auto or Personal Injury – A written statement from a legitimate insurance company containing the insurance company’s name, address and phone, injury date, claim number, and billing information must be presented prior to initial service. Insurance company will be billed for all services provided to you. In the event insurance denies payment, patient will be responsible for all charges incurred during treatment. *

Cancellation / No-Show Contract.

Cancellation/No-Show Contract There is a charge of $75 billed to patient for each no-show appointment, for each cancellation in which patient fails to provide 24-hour notice, and for arriving 15 minutes or more late to an appointment time. This fee is patient responsibility not insurance. Two no-show appointments will result in automatic discharge. Patients will be provided with a paper copy of their scheduled visits. Please note, appointments are patient responsibility to place on their Calendar and adjust if rescheduled. Email, text, and call reminders are sent only as a courtesy to patients. Failed receipt of a reminder resulting in a missed appointment will incur a no-show fee charge of $75. *

Cancellation/No Show Policy: Charge of $75 fee billed to patient for each No-Show or for each failer to provide 24 hour notice for cancellation. *

To maintain appointment availability for all of our valued patients, there is a charge of $75 billed to patient for no-show appointments in which patient fails to provide 24-hour notice. This fee is patient responsibility. Two no-show appointments will result in automatic discharge. I acknowledge I have been made aware of this policy and fee incurred for missed appointments.

Voice Messages – Progressive Physical Therapy has permission to leave voice messages on my phone regarding appointments. AN INITIAL INDICATES A “YES” RESPONSE. Please leave blank if permission is denied.

I have been given the opportunity to view and/or received a copy of the Notice of Privacy Practices and understand that I may request a copy at any time. A copy of our NOTICE OF PRIVACY PRACTICES can be viewed here: https://progressiveptgreenvalley.com/notice-of-privacy-practices/

With your electronic signature below, you are agreeing to the terms laid out in previous pages, consent to treatment, authorize the release of any/all medical information necessary for treatment, and for insurance companies or third parties to process claims for evaluation and treatment provided by PROGRESSIVE PHYSICAL THERAPY. You also authorize the direct assignment of insurance benefits to PROGRESSIVE PHYSICAL THERAPY for evaluation and treatment, and service rendered. This includes basic benefits, major medical benefits, and all medical payment coverage from all insurance policies otherwise payable to you. You understand that you are financially responsible for any charges not covered by this assignment. I do hereby consent to such treatment by authorized personnel of PROGRESSIVE PHYSICAL THERAPY, as dictated by prudent medical practice. I also consent payment to be made by my insurance carrier to PROGRESSIVE PHYSICAL THERAPY. This consent is intended as a waiver of liability for such treatment excepting acts of negligence.

Electronic Signature: *

Date: *

Acceptance Checkbox *

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.

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