Fredericksburg Orthopaedic Associates, P.C. Logo PHYSICAL THERAPY TREATMENT
POLICY FORM
(This Form is to be printed.)
(Page 1 of 1)
 

PLEASE ENSURE TO BRING THIS FORM WITH YOU TO YOUR INITIAL APPOINTMENT. DO NOT DROP IT OFF BEFOREHAND.

 

The following is a brief explanation of our policies regarding physical therapy treatments.

THE PHYSICAL THERAPY DEPARTMENT IS PART OF FREDERICKSBURG ORTHOPAEDIC ASSOCIATES, A DIVISION OF MID-ATLANTIC HEALTH ALLIANCE, INC. IF YOU CHOOSE TO HAVE YOUR PHYSICAL THERAPY PERFORMED AT ANOTHER FACILITY, WE WILL BE GLAD TO REFER YOU.

An itemized list of charges for your treatment will be given to you after every visit to the therapy department. Payment in full will be expected at the time of each visit unless proof of full or partial insurance coverage for physical therapy has been furnished. If you have partial insurance coverage, you will be expected to pay the non-covered amount. If you cannot do this, arrangements must be made with our collection manager prior to your appointment.

We request notification of 24 hours prior to your appointment should you need to cancel. This allows us the opportunity to schedule another patient.

If you have any questions or concerns, please discuss them with us so we can serve you better.

 

(I have read and understand the above policies.)

 

Patient/Guardian
Signature:
_____________________________
Date: _____________________________