We strive to provide our patients with excellent service and quality care. We will recommend treatment and set goals for you. In order to reach those goals, appointments must be attended. We would appreciate 24‐hour notice if you need to cancel an appointment so we can fill your appointment time. If you do not give 24 hours notice or you fail to show for a scheduled appointment, a $50 fee will be billed to you. Our number is 617‐860‐6430. If you miss 3 consecutive appointments, we may have to notify your physician and will require a new referral in order to continue your treatment.
Our staff will contact your insurance company to verify your physical therapy benefits and let you know what your responsibility will be at the time of service.
We encourage you to call your insurance provider to discuss your coverage and what your financial obligations may be.
Please speak with our Front Desk Specialist if you have any questions regarding your appointments, insurance, financial responsibilities, or any other issues.
Please speak with your therapist if you have any questions regarding your Physical Therapy treatment. We thank you for choosing POST Physical Therapy and we look forward to working with you and helping you.
Patient Location: Is the patient under 18 years of age?: Appointment Reminders: Type of Reminder: Email tips and offers: Legal Sex: Have you had Physical Therapy this calendar year?: How did you hear about us? Doctor: Social Media: Online Review: Other: Referred by: Other referral: Trainer: Other source: Have you had Physical Therapy this calendar year?: How many visits and when?
Do you have the required PT Order?
Is this a motor vehicle or workman's comp claim?: Is subscriber's address the same as patient?:
Do you have Secondary Insurance?*
Did you receive Physical Therapy for this?: Has your condition been getting: What are your current medications?: Mark the number that best corresponds to your pain below: Your pain at its most painful: Your pain at its least painful: Please describe the nature of your pain (checked all that apply): What decreases pain/makes your condition better?: What increases pain/makes your condition worse?: Previous Medical Intervention: Do you have additional documentation? Documentation:
I hereby instruct the insurance company/companies to pay by check made out to and mailed directly to POST Physical Therapy for professional or medical expenses allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for professional services rendered.
This payment will not exceed my indebtedness to the above-mentioned assignee By signing below I have agreed to pay, in a current manner, any balance of said professional fees for non-covered services and/or fees, over and above the insurance payment or as required by my insurance policy. I understand that POST Physical Therapy complies with HIPAA and will protect my Protected Health Information (PHI) and will use it as allowable by law in the treatment, billing, and collection pertaining to my care until my case is closed and full payment is received. I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or an attorney for the purpose of securing payment under this policy of insurance or to any Medical Provider associated with my case to effectively treat me. The authorization is in effect until 90 days from the date the last bill is collected.
A photocopy of this Assignment shall be considered effective and valid as the original. I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney for the purpose of securing payment under this policy of insurance under the HIPAA guidelines.
I hereby authorize the professional staff at POST Physical Therapy to examine and treat me with physical therapy for the injury I have been referred here for or referred me to. I also authorize my protected health information to be disclosed to my insurance company (s), my doctor and /or other healthcare providers as well as my attorney.
By signing below I authorize benefit payments directly to POST Physical Therapy that would otherwise be payable to me. I authorize POST Physical Therapy to securely store my credit card information, and only charge it should I have a co-payment, cancellation fee, deductible, coinsurance, or any leftover balance from a processed claim.
I understand that it is my sole responsibility to notify you in a timely manner of any change to the information I have provided. If I do not cancel or reschedule an appointment without giving at least 24 hours notice I may be charged a fee. If a check I provide bounces I understand there is a $50 fee. POST strongly suggests that I the patient contact my insurance company to verify benefit information. However, POST assumes no liability for any misunderstanding or errors made by my insurance carrier in regards to the information received and what my ultimate responsibility is for visits.
If no or incorrect insurance information is provided by the patient, visits will be processed at the self-pay rate. POST expects payment at the time of service. A prescription for Physical Therapy from a physician is required.
REMINDER PHONE CALLS ARE A COURTESY AND SHOULD NOT BE RELIED UPON FOR KEEPING TRACK OF YOUR APPOINTMENTS.
All patients should be guaranteed the following freedoms:
To receive full disclosure of their insurance plan in plain language, including:
Leave this empty:
Your legal name
Your email address
Signed by POST PT Luke Ferdinands
Signed On: July 18, 2023
If you have questions about the contents of this document, you can email the document owner.
Document Name: Patient Agreement
Agree & Sign