PATIENT PAYMENT RESPONSIBILITY

Patient Name(Required)
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PATIENT PAYMENT LIABILITY: I acknowledge that I am legally responsible for all services provided by Leaps and Bounds Therapy, LLC and I assign and authorize payment to Leaps and Bounds Therapy by my insurance carrier for services provided to me or to the patient named above.

I further understand that:(Required)

SCOPE AND TERM OF AGREEMENT: This agreement covers any services received by Leaps and Bounds Therapy, LLC which includes: Physical Therapy

This agreement remains in effect for the entire time that therapy services are rendered from leaps and Bounds Therapy, LLC unless replaced with another signed document at a later date.

FAMILY MAXIMUM OUT OF POCKET PLANS

All patients who are uninsured, out of network, denied coverage by insurance or who choose not to utilize insurance for other reasons are eligible for consideration of reduced pricing. Please contact aneri@leapsandboundsil.com for more information.
Name of responsible party(Required)
Signature of responsible party(Required)
By completing this document I am agreeing that my responses are truthful and I accept the responsibility of digital signature.
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