Patient Registration & Consent of Treatment
If we are billing your insurance company, we recommend that you contact your insurance carrier to understand your benefits and coverage. A verification of your benefits as described by your insurance company, is not a guarantee of payment. I understand that GO PT, PLLC will bill my insurance company directly, but that I am personally responsible for any copays, deductibles, or balances incurred. If my insurance company denies claims or my claims go to medical review I understand I am financially responsible for all services.
If your visit with us is Motor Vehicle Related, we will only bill PIP coverage, we do not accept 3rd party claims. For privately insured patients we can bill both primary and secondary insurance.
Invoices on patient responsibilities not paid within 30 days of the statement date will result in a $10 per month late fee. These late payment fees will not be covered by your insurer. By signing this agreement, you are consenting to this late payment policy and agree to pay any assessed late payment in full to settle your account.
Account balances (patient responsibility) over $500 for more than 60 days from original invoice date will result in a temporary scheduling hold. Patients must make a minimum payment to be under that threshold or arrange a payment plan with the clinic in order to satisfy balance to remove scheduling restrictions. A minimum payment is 25% of invoiced total balance in order to avoid late payment fees.
We are not MEDICARE providers and cannot bill Medicare or supplemental coverage. Payment for any co-pays or supplies should be paid at the time of your visit. We accept cash, check, and most major credit cards. GO PT will charge a $25.00 NSF check fee, if necessary.
I authorize my insurance benefits be paid directly and mailed to: GO PT 201 Yale Ave N. Seattle, WA 98109. I understand I am responsible for any amount not covered by my insurance, and for any costs incurred for collection on my account. I authorize GO PT, PLLC to furnish information concerning my illness and treatments to my insurance carriers. A photocopy of this assignment shall be considered as effective and valid as the original.
**We can bill Secondary Insurance only if we are in network**
I, the undersigned certify that I (or my dependent) have insurance coverage with the above listed insurance and hereby authorize you to evaluate and treat me (or my dependent) and I assign directly to GO PT, PLLC all medical benefits, if any, for services rendered. I authorize the release of all information necessary to secure payment of benefits. I authorize the release of medical and billing information to my referring physician or insurance company if requested.
If you need to cancel or reschedule your appointment, we ask that you notify us via email or phone at least 24 hours before the start time of your appointment. Failure to do so will result in a $50.00 charge which is not payable by insurance. Repeated no-shows/cancellations within a 24 hour period of your appointment will also result in us only being able to offer same day scheduling for your appointments.
Being late to your appointment will result in a late fee. Being 10-20 minutes late for your appointment will result in a $25.00 charge, and being 20-30 minutes late will result in a $50.00 charge, not payable by insurance. Having a late fee balance of $100.00 or more will result in us only being able to offer same day scheduling for your appointments.
If tardiness, late cancellations and no-shows continue to be an issue, GO PT reserves the right to dismiss patients from our care.
I, certify that I (or my dependent) have insurance coverage with above listed insurance and hereby authorize you to evaluate and treat me (or my dependent) and I assign directly to GO PT, PLLC all medical benefits, if any, for services rendered. I authorize the release of all information necessary to secure payment of benefits. I authorize the release of medical and billing information to my referring physician or insurance company if requested.
I, consent to the use or disclosure of my protected health information by GO PT for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of GO PT.
I understand that diagnosis or treatment of me by GO PT may be conditioned upon my consent as evidenced by my signature on this document.
I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or health care operations of the practice. GO PT is not required to agree to the restrictions that I may request. However, if GO PT agrees to a restriction that I request, the restriction is binding on GO PT.
I have the right to revoke this consent, in writing, at any time, except to the extent that GO PT has taken action in reliance on this consent.
My “protected health information” means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.
I understand that I have a right to review GO PT’s notice of privacy practices prior to signing this document.
The GO PT Notice of Privacy Practices has been provided to me.
The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of heatlh care operations of the GO PT.
This Notice of Privacy Practices also describes my rights and the duties of GO PT with respect to my protected health information.
GO PT reserves the right to change the privacy practices that are described in the Notice of Privacy Practices.
I may obtain a revised notice of privacy practices by accessing the GO PT’s web site, calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.
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If you have questions about the contents of this document, you can email the document owner.
Document Name: Patient Registration & Consent of Treatment
Agree & Sign