PLEASE DO NOT COMPLETE THE FOLLOWING SECTIONS ON FIRST VISIT
I acknowledge that I have reviewed the information listed and confirm that there are no changes to my demographic and insurance information.
Thank you for choosing Rock Valley and providing us the opportunity to work with you. We hope to exceed your expectations and assist you in achieving your goals.
Notice of Privacy Practices:I acknowledge being offered Rock Valley Physical Therapy’s Notice of Privacy Practices pamphlet. I have initialed here to indicate that I understand my rights through HIPAA and that I am declining this pamphlet.
Authorization to Release Information:I authorize the release of any medical or any other information to the Centers for Medicare and Medicaid Services (CMS), my insurance carrier(s), or other entities necessary to determine insurance benefits or the benefits payable for related medical services and /or supplies provided to me by Rock Valley Physical Therapy.
Financial Responsibility:I understand that insurance billing is a service provided as a courtesy and that I am, at all times, financially responsible to Rock Valley Physical Therapy. It is my responsibility to notify Rock Valley Physical Therapy of any changes in my health care insurance coverage. If the submitted charges or any part of them are denied for payment, I am responsible for the balance. I request that payment of my services be made on my behalf to Rock Valley Physical Therapy. I understand that by signing this form, I am accepting financial responsibility, as explained above, for payment of the balance of all medical services. I also understand that Rock Valley Physical Therapy collects for copayments at the time of service.
Supply Items:I understand that Rock Valley Physical Therapy may, during the course of treatment, recommend purchase of a supply item. Supply items may or may not be covered under my insurance plan. I understand that it is my financial responsibility to pay for any item in full if it is not covered under my insurance plan.
This is to verify that I have read and agree with the above.
Rock Valley Physical Therapy does not discriminate against any person on the basis of race, color, national origin, disability, or age in admission, treatment, or participation in its programs, services and activities, or in employment. For further information about this policy, contact the administrative assistant at (309)-743 2070. TDD/Relay Iowa.