Patient Responsbility: Your insurance company may require a deductible, a co-payment, and/or co-insurance from you. Any deductible, co-payment, and/or co-insurance must be paid at the time of service. Your co-payment/co-insurance may not be your only liability. If your insurance denies the services for any reason or considers the services non-covered, you are ultimately responsible for payment for the service you received.
I hereby instruct and direct my insurance company to pay by EFT or check made out to Functionabilities and mailed to PO Box 363, Riverton, UT 84065 (not to me). If my current policy prohibits direct payment to doctor/ therapist, I hereby also instruct and direct you to make the check payable to me and mail it to the above address for the professional or medical expense benefits allowable, and otherwise payable to me under my current insurance policy as payment toward the total charges for the professional services rendered. I will promptly upon receipt sign over all checks pertaining to services here.