Signature & Insurance Assignment – Center for Physical Therapy

Signature & Insurance Assignmenthudsonvalleywebgirl2022-09-07T10:54:17-04:00

Signature on File & Insurance Assignment

I hereby authorize Center for Physical Therapy to file insurance claims on my behalf and to furnish any and all records pertaining to medical history, services rendered or treatment given to me or my dependants for purposes of review, investigation or evaluation of my insurance claims. If my coverage is under a group contract held by my employer, an association, trust fund, union or similar entity, this authorization permits disclosure to them for purposes of utilization review or financial audit. If my insurance policy allows, I hereby “assign” or “authorize” direct payment to Center for Physical Therapy toward any physical therapy services performed. This authorization shall become effective immediately and shall be valid until rescinded in writing or replaced by one of a later date. A photostatic copy of this authorization shall be considered as effective and valid as the original.

Patient Name: *First, Middle, Last

Patient's Age *

Patient Signature *

Date

Parent or Legal Guardian Name: *

Relationship to Patient

Parent or Legal Guardian Signature

Date

I hereby authorize and request my insurance company to pay directly to Center for Physical Therapy the amount(s) due to my claim for services rendered to me or my dependant. I further agree that should the amount be insufficient to cover the entire medical expense, I will be responsible for payment of the difference; and if the nature of the disability be such that it is not covered by the policy, I will be responsible to the Center for Physical Therapy for payment of the entire bill. If previous arrangements have not been made with our billing department, any account balance outstanding greater than 90 days with no monthly payments made will be forwarded to a collection agency. Accounts placed with a collections agency will incur all collections fees.

Patient Signature

Date

Insured Signature

Date