As a courtesy to our patients, OrthoSports Physical Therapy will bill your primary insurance
carrier. Upon receipt of payment from your insurance company, the allowed balance will be transferred
to you. While we accept most insurance, payment amounts vary based on your specific plan. We suggest
that you contact your insurance carrier to determine what is covered for physical therapy services by
Co payments are due at the time of service. If you have to cancel your appointment, do so in 24
hours in advance. Should you cancel on the same day or not attend a scheduled appointment there will be
a $40 charge for the missed visit.
An itemized billing statement of the services provided to you is available at anytime per your request.
Please ask the receptionist, therapist, or you may call the billing office at 602-315-9762.
I have read and fully understand OrthoSports Physical Therapy's notice of Information Practices.
I understand that OrthoSports Physical Therapy may use or disclose my personal health information
for the purposes of carrying out treatment, obtaining payment, evaluation of the quality of services provided
and any administrative operations related to treatment or payment. I understand that I have the right to restrict
how my personal health information is used and disclosed for treatment, payment, and administrative operations
if I notify the practice. I also understand that OrthoSports Physical Therapy will consider requests for
restriction on a case by case basis, but does not have to agree to the request for restrictions.
I hereby consent to the use and disclosure of my personal health information for purposes as noted in OrthoSports
Physical Therapy's Notice of Information Practices. I understand that I retain the right to revoke this consent by notifying
the practice in writing at any time.
CONSENT FOR TREATMENT: I understand that I have the right to ask and have any questions answered
prior to receiving treatment, including any risks or alternatives to the treatment plan that has
been prescribed for me.
By choosing a payment option and signing this form, I consent to have an
OSPT physical therapist provide treatment.