Billing

I authorize the payment of benefits as determined by my insurance company(s) to be made directly to the Center for Physical Rehabilitation Incorporated.  I understand that I will be responsible for and must pay any percentage, any co-pay, any deductible, and any amount not covered by my insurance.  In addition, if the insurance company will not pay charges as they are received, I agree to make monthly payments on the account to maintain a current status. 

 

I, ____________________________, agree to make monthly payments on my account if the insurance company will not pay my claims.

 

Patient Signature: ___________________________ Date: _______________________

Medical Records

I authorize the Center for Physical Rehabilitation Incorporated to release any medical information requested with regard to this injury/illness and the expenses reported regarding my treatment.  

 

Patient Signature: ___________________________ Date: _______________________