As a standard practice, ProHealth Physical Therapy and Pilates Studio collects all expenses that are the responsibility of the patient at the time of service. This request for payment will include any deductible, co-pay and coinsurance amounts that apply to my visit. I understand that as a courtesy, ProgressiveHealth of Indiana will bill my insurance directly for the services I receive, but this is not a guarantee that my insurance will pay for services rendered or materials received. It is my responsibility to know my insurance benefits and coverage.
In some cases, the amount of charges is an estimate based upon information provided directly by my insurance company regarding my particular plan and eligibility and the procedures performed. However, the exact amount of all charges may not be known at the time of service as my insurance may process differently than anticipated. It is possible that additional expenses that are my responsibility may be reflected on my final statement. In such a case, the payment collected at the time of service serves as a deposit towards my final balance. Additionally, any overpayment will be promptly refunded to me after all claims have been processed by all applicable payers.
In the event that there is a past due balance on my account, it will be submitted to a collection agency, and I agree to pay all attorneys’ fees and court costs incurred by ProHealth Physical Therapy and Pilates Studio in the collection of my account.
I understand that if I anticipate problems paying my portion of my bill, I should let the Front Office Coordinator know as soon as possible, so that payment alternatives may be discussed, should I qualify.
I authorize ProHealth Physical Therapy and Pilates Studio or its agents to contact me via manual or auto-dial telephone call in order to collect any amounts I may owe, including calls to my cell phone number, if I have provided that number. I also agree that any email address I have provided is my personal email address and I authorize ProHealth Physical Therapy and Pilates Studio or its agents to contact me via that email address.
I acknowledge that I have read, understand, and agree to all of the terms above.