Release Form

Release Form

This form is to be filled out prior to a first visit for yourself or a minor child. By inserting your name in the noted boxes you are agreeing to the terms indicted. REFERRALS: If your insurance requires a referral this must be present at the start of care. COPAYMENT Copayments are due on the day of service. CONTACT YOUR INSURANCE You are strongly advised to contact your insurance company to verify benefits and authorization requirements as well as determining deductibles, copayments and coinsurance for physical therapy services. It is your responsibility to understand your health benefits outlined in the coordination of benefits with your insurance carrier. Pinnacle is not responsible for unpaid services which are not provided by your health insurance. BILLING & PAYMENTS You will be billed in accordance with this agreement to pay for services that are denied by your insurance carrier but are legally billable to you under the terms of your plan. If a payment is due from you our term is net 30 days.

  • I authorize Pinnacle Physical Therapy, Inc. to bill my insurance company and to receive any payment directly from the company for services provided.
  • I agree that I am responsible for timely and full payment for services provided which may include my employer’s workers’ compensation or automobile policies and services that are not covered due to deductibles, co-payment, denial or exclusions specific to my health plan.
  • Please kindly give us 24 hours notice if an appointment cannot be maintained.
  • I consent to physical therapy treatment at Pinnacle Physical Therapy, Inc. on behalf of myself or my minor child.
  • I give permission for Pinnacle Physical Therapy to contact the individual or groups named below. Please write the names of entities that you are releasing Pinnacle Physical Therapy to talk with in order to facilitate your care. This could be you referring physician, your insurance company or a family member.