Patient Payment Responsibility Form - Leaps and Bounds Pediatric Therapy

PATIENT PAYMENT RESPONSIBILITY

Patient Name(Required)

First Last

Patient Date of Birth(Required)

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)

It is my responsibility to confirm my insurance benefits and options and to provide correct and current information regarding my policy to Leaps and Bounds Therapy, LLC.

My insurance carrier may not approve or reimburse my services for reasons including but not limited to usual and customary rates, benefit exclusions, coverage limits, lack of authorization, or lack of medical necessity.

Leaps and Bounds Therapy will work to receive pre-authorization from my insurance company if it is required. If insurance approves services and later refuses to cover them it will be my responsibility to cover the costs and appeal to my insurance company to correct the denials. Pre-authorization may or not may not be required for services.

I will pay for costs which are not paid for by insurance within 30 days of received invoice from Leaps and Bounds Therapy.

If I receive any reimbursement directly from my insurance company to apply toward these services, I will inform and reimburse Leaps and Bounds Therapy LLC accordingly.

I verify that the demographic and insurance information provided to Leaps and Bounds Therapy, LLC is correct, and it is my responsibility to immediately update Leaps and Bounds Therapy with any changes as they occur.

In the event, that I default on any of the terms of this agreement, I agree to pay all costs of collection and reasonable attorney’s fees associated with Leaps and Bounds Therapy’s attempt to secure payment from me.

Payment can be sent within 30 days of receipt of invoice electronically via Zelle to Leaps and Bounds Therapy email: aneri@leapsandboundsil.com or electronically by your bank or by check to the business address listed on the invoice.

I authorize Leaps and Bounds Therapy to email my statements and other therapy information to me and acknowledge that this is via non-secure email.

Preferred Email

I authorize the release of any medical information necessary to process claims and consent to the rendering of care and services by Leaps and Bounds Therapy for myself or for the patient named above.(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)

First Last

Relationship to patient(Required)

Signature of responsible party(Required)

First Last

By completing this document I am agreeing that my responses are truthful and I accept the responsibility of digital signature.

Date(Required)