Patient Information

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Montgomery Center

Date of Birth *
Date of Birth
Mailing Address *
Mailing Address
Home Phone *
Home Phone
Cell Phone
Cell Phone
Primary Insurance Information
Secondary Insurance Information
Patient Employer Information
Financial Policy *
The entire Oxford Physical Therapy team would like to thank you for making us your preferred family physical therapist and health care provider. We are committed to your treatment being successful. All prospective patients must fill out and complete a patient information and consent form before being seen by an Oxford Physical Therapist. Financial responsibility for treatment is an obligation to the patient. As a courtesy, Oxford Physical Therapy will bill the appropriate insurance carrier on the patient's behalf. Remaining balances after insurance payment are the responsibility of the patient and are "Due within 90 Days of Treatment". Prompt payment allows Oxford Physical Therapy to continue providing quality and cost effective patient treatment. Patients should contact the Oxford Physical Therapy bi11i ng department at 513.701 .61 00 to arrange a payment schedule if they are not able to meet their financial obligation. Regarding Your Insurance - Important! Oxford Physical Therapy requires the patient co-payment at the time of treatment. If co-payments are not paid at the time of service a $15.00 late fee may be assessed to the patient's bill. In the event patient's insurance changes to a plan where Oxford Physical Therapy is no longer in network, refer to the above paragraph. It is the patient's responsibility to know their benefits. Disputes regarding deductibles, co-payments, covered charges, "usual and customary" charges, etc. are handled between the patient and their insurance company. Regarding Insurance Billing: If current and accurate insurance is provided at the time of service, Oxford Physical Therapy will bill the patient's insurance company in a timely manner. All patient claims are due and payable within 90 days of receipt of the insurance claim form. However, in the event that repeated billing to the patient's insurance carrier does not satisfy the patient's balance, that patient assumes the financial responsibility of the remaining balance. If current and accurate insurance information is not provided within the limits of timely filing, that insurance will not be billed. If a patient has secondary insurance it must be presented at the initial time of service. Oxford Physical Therapy will not retroactively bill a secondary insurance if there is failure to provide all of the necessary insurance information at the time of service. The balance becomes the patient's obligation and is responsible for submitting claims to secondary insurance companies. If the patient receives payment from an insurance company or an attorney for services rendered by Oxford Physical Therapy, it is the patient's responsibility to reimburse Oxford Physical Therapy in full at the time of receipt of such payment. The patient agrees that if he or she defaults on any balance owed Oxford Physical Therapy and it becomes necessary for Oxford Physical Therapy to engage the services of an attorney, collection agency or other lawful method of collection, the patient will pay the original balance owed and reimburse Oxford Physical Therapy for all costs incurred by it in the collection of said debt. Oxford Physical Therapy accepts Cash, Check, & most major credit cards. Payments may be made at any local Oxford Physical Therapy treatment center, on our website, or by calling the Oxford Physical Therapy billing staff at 513.701.6100. ***If paying by check you understand and authorize all dishonored checks plus a processing fee with applicable taxes to be charged to your account. Missed Appointments and Late Charges: Oxford Physical Therapy requires a 24 hour advanced notice for all appointment cancellations or a $40.00 fee may be billed directly to the patient for missed appointments. Minors: The adult accompanying a minor is responsible for payment. Auto Insurance: Oxford Physical Therapy will submit claims to patient Med Pay with your auto insurance. If patients do not have Med Pay, we will submit claims to patient's health insurance. Co-payment and co-insurance balances will be due and payable within 90 days of receipt of the insurance claim. Oxford Physical Therapy will not bill third party insurances.
Consent to Treat and Authorization to Release Information *
I hereby authorize Oxford Physical Therapy, through its appropriate personnel, to perform the evaluation and treatment procedures that are deemed necessary by my physicians and physical therapist in the treatment of my condition. I further authorize Oxford Physical Therapy to furnish and/or disclose my personally identifiable health information to the appropriate agencies for the purpose of billing. I have had the opportunity to review Oxford Physical Therapy’s Privacy Notice prior to signing this consent. I understand that I have the right to request restrictions on the uses and disclosures of my protected health information for treatment, payment and healthcare operations, but Oxford Physical Therapy is not required to agree to such a request, but if Oxford Physical Therapy does agree to my request, the restrictions will be binding. I am allowing a photocopy of my signature to be used for insurance purposes. I also authorize my insurance company to pay directly to Oxford Physical Therapy the amount due me in my pending claim for insurance.