Only good for the case listed below - additional form will need completed for each case
I hereby certify that I have been informed of the usual fees for the examination, testing and treatment that have been recommended.
I am unable to pay those fees at this time without substantial financial hardship and peril.
I have no expectation of being able to recover those expenses from any third party or insurance benefit.
To enable me to obtain the recommended services, Tristar Physical Therapy and I have agreed to a special payment arrangement under which I will pay $ ______ for each visit instead of ____________ that my insurance benefits states would be my financial responsibility.
I understand that I must come for the recommended plan of care (example 3 times a week for 4 weeks or 2 times a week for 6 weeks, etc that my therapist has set up or I will be charged for all copayments or coinsurance that my insurance states I'm responsible for.
Should my financial circumstances change so that I am able to pay the regular office fee without substantial hardship and peril or I am able to recover expenses from a third party or insurance benefit, I will inform the office of such change.
As such, I will be charged the usual and customary office fee for therapy. It is my responsibility to make these payments without any need for periodic bills or other reminders of payments due.
The discounted amount MUST be paid EACH visit, no exceptions.