Financial Policy - Pelvic Health

Step 1 of 2

  • Financial Policy: Participating & Non Participating Insurances

  • Pelvic Health (PH) agrees to bill my insurer for services. Following payment from my insurance company, I am responsible for any amounts due including deductibles, coinsurance, or any other charges not covered by my insurance.

    I understand that co-pays are due at the time of each therapy visit. Failure to pay at the time of my visit may result in an additional 5$ fee to be paid by me for each late co-pay.

    I understand that the all cancellations are to be made 24 hours prior to my visit. Pelvic Health reserves the right to charge a $40 fee for missed or cancelled appointments.

    It is imperative that I provide Pelvic Health with all insurance information (primary, secondary, etc) as well as any changes in my insurance prior to each visit. Failure to do so will result in my being responsible for any and all charges that Pelvic Health is unable to collect for as a result.

    Interest will accrue at 1.5% per month on any balance over 30 days old that is deemed my responsibility. If my account is sent to collections and/or small claims court, I will be responsible for any collection expenses and/or court costs.

    I authorize release of any medical information necessary to process any insurance claims and I authorize payment of medical benefits directly to Pelvic Health for myself and/or my dependents.

  • By typing your name in the space below you are providing an "electronic signature" and it indicates your approval of the information contained in this electronic form.
  • Date Format: MM slash DD slash YYYY