Amanda Kayser, LLC
Financial Responsibility and Medicare Opt-out
Note: Please read carefully
With services delivered in the privacy and comfort of your own home, Amanda Kayser, LLC is able to optimize treatment time while providing you with our dedicated attention and effort. As a concierge service, our energy is completely focused on you, and not influenced by the direction of a third-party payer. This allows us to deliver healthcare in the purest sense and with the highest levels of professionalism.
In order to maintain highly competitive rates for one hour of personal dedicated service, Amanda Kayser, LLC chooses not to be contracted with insurance companies, including Medicare. Having contractual agreements with insurance companies imposes limitations on your care. It is the philosophy of Amanda Kayser, LLC that YOU, the individual, should have control over YOUR care, regardless of the reason(s) for which you are seeking out services; whether it be for maintaining optimal health, resolving a nagging pain, or recovering from a surgery or a serious injury, or other.
For Medicare eligible clients, it should be noted that in signing this Financial Responsibility, you are choosing to opt-out of your Medicare benefits, including submission to Medicare for potential reimbursement. Federal regulations require that a Medicare eligible client acknowledge and sign such a waiver when choosing to engage in private-pay services.
It is requested that payment be made in full at time of service. Amanda Kayser, LLC is happy to provide you with an electronic invoice/statement for you to file on your own should you so desire.
Thank you for choosing Amanda Kayser, LLC to assist you in your therapy and wellness needs. We look forward to being your personal therapist of choice.
Amanda Kayser, PT, DPT, NCS TX#1253955
Amanda Kayser, LLC
By signature of this Financial Responsibility, I _______________ acknowledge that services provided by Amanda Kayser, LLC are on a cash basis and that no claims for insurance payment will be filed by Amanda Kayser, LLC on my behalf.