Authorization to Treat

I hereby authorize the release of medical records to Complete PT and any pertinent information concerning the patient for the provision of care and for obtaining insurance reimbursement.

I hereby assign all insurance benefits for services rendered to which I am entitled to be paid directly to Complete PT. I understand that if my insurance company/third party payer denies payment or makes partial payment, I am responsible for the balance due.

I understand that as a courtesy, Complete PT will verify my benefits specific to outpatient physical therapy but that I am legally responsible for payment of all services rendered by Complete PT. It is your responsibility to know your insurance benefits. We always ask that you also call your insurance and double check the information we are provided.

If my insurance is being billed, I will be responsible for paying any deductible amounts. I understand that co-payments are due at time of service. (This does not apply to worker’s compensation patients.)

If your deductible has NOT been satisfied you are required to pay $130 for the evaluation, then $75 per visit at the time of service until your deductible is satisfied. You will then be billed the remaining amount, if there is any. If your out of pocket maximum has NOT been satisfied you are responsible to pay the approximate co-insurance amount per visit until the amount is satisfied. You will be billed the remaining amount, if there is any.

You will be billed monthly once your insurance has processed visits. You will NOT receive a bill until insurance has processed visits.

No Call No Show and frequent and/or last minute cancellations within 24 hours could result in a $100 fee. Your first offense will be waived, then moving forward you will be charged a $100 fee. We understand situations happen, we just ask you to respect us and openly communicate.

Rici Lowe with Elite Medical Billing is our billing specialist and she is based in Idaho. Therefore, the number she calls you from will have an Idaho area code. If any problems arise with any claims her company may contact you.