Advance Physical Therapy
810 E. Sunflower Rd, Suite 150
Cleveland, MS 38732
Billing Information
In an effort to provide you with the highest quality of care possible, we feel that it is important that you understand how you will be billed for the services that you receive.
In accordance with the law, al insurance companies are billed the same amount for the same service. However, our clinic has individual contracts with "PPO Networks" that allow us to charge an allowed fee for services provided. You will not be held responsible for any amount over that contracted amount. You will be billed for these services after we receive payment/denial from your insurance company. Payment plans are available to help you pay your balance in a timely manner. If your bill becomes delinquent without any effort of payment, your account will be placed with our collection/legal department for payment.
Informed Consent
I authorize Advance Physical Therapy to perform treatment to me/my child in accordance to my physician's orders. I understand that I can refuse treatment and that an explanation of possible consequences resulting in the refusal of treatment
will be provided to me, and my physician will be notified. I also acknowledge that I have received a copy of the Patient's Bill of Rights by this facility, and understand my rights therein.
I request that my payment of my Medicare/Insurance Company benefits be made to Advance Physical Therapy for any services to me. (If you have Medicare, regulations pertaining to the assignment of benefits apply). I authorize the release of my medical records/information in order for the clinic to be reimbursed for services rendered to me. I permit this copy of this authorization to be used in place of the original. I understand that it is mandatory to notify the healthcare provider my treatment.
(Section11288 of the Social Security Act 31 USC 03801-3812 provides penalties for withholding this information.)
Use and Disclosure of Your Protected Health Information
Your protected health information will be used by Advance Physical Therapy to others for the purposes of treatment, obtaining payment, or supporting the day-to-day health care operations of our practice.
Notice of Privacy Practices
You should review the Notice of Privacy Practices for a more complete description of how your protected health information may be used or disclosed. You may review the notice prior to signing this consent.
​
I have reviewed the Notice of Privacy Practices and give my permission to Advance Physical Therapy for the use and disclosure of my health information in accordance with it.
​
​
