New Patient Agreement - Cash Pay

You may pay cash for STEP UP Physical and Occupational Therapy services.

• Physical or Occupational Therapy Evaluation: $150
• Physical or Occupational Therapy Treatment Session: $110
• Personal Training Session: $110

Please read the following information:

• Payment is due at time of service for any cash pay service.
• We accept cash or check (make payable to: STEP UP Physical Therapy, PLLC)
• Cancellation/appointment policy: Unless you cancel at least 24 hours in advance, our policy is to charge $50.00 per missed appointment. This will allow us to fill your appointment slot with someone who may need care urgently.

By signing below I understand and agree to this Financial Policy and acknowledge I have read the notice of privacy practices.

Permission to Treat

New Patient Agreement - Medicare

We are a Medicare Provider. Your insurance benefit is described below:

• Outpatient Physical Therapy Benefit Threshold (2024): $2,330 (~18 visits). You may qualify for coverage beyond that amount.
• Outpatient Occupational Therapy Benefit Threshold (2024): $2,330 (~18 visits). You may qualify for coverage beyond that amount.
• Annual Deductible (for 2023): $240
• Coinsurance: Medicare considers 80% of charges. Secondary insurance or patient responsibility 20%.
• Copayment: None

Notes: You must not currently be receiving Medicare covered home health care in order for Medicare to pay for this outpatient service. This includes home health nursing, home health aide, home health therapy (speech, occupational, physical).

Billing policy for therapy: We will bill Medicare and your secondary/supplemental plan for services.

Important: This is not a guarantee of payment for services. This is strictly a description of your benefits for outpatient physical and/or occupational therapy. If you do not feel this benefit is correct, please contact your insurance company. Ultimately, you are responsible for ANY amount not covered by your insurance company.

Please read the following information:

• Your insurance policy is a contract between you and your insurance company. We will bill your insurance company on your behalf. Any amount not covered or denied by your insurance company is your responsibility. If your insurance company has not made payment on your account within 90 days, you must pay your account in full or make arrangements for a payment plan. You may then contact your insurance company for reimbursement. Should your account be sent to collections, we reserve the right to charge interest on the overdue balance in the amount of 21% as approved by law.
• We cannot bill your insurance company unless you give us your current insurance information. Please notify us of any changes. In the event your insurance company changes and we are not a participating provider, you may be responsible for these charges.
• Payment is due at time of service for any cash pay service. Once your insurance company has processed your claim, any remaining balance is your responsibility to be paid within 30 days of billing date. In the event that your insurance policy changes and we are not a participating provider, you may be responsible for these charges.
• Cancellation/appointment policy: Unless you cancel at least 24 hours in advance, our policy is to charge $50.00 per missed appointment. This will allow us to fill your appointment slot with someone who may need care urgently. Your insurance company will not cover missed appointment fees.

By signing below I understand and agree to this Financial Policy and acknowledge I have read the notice of privacy practices.

Permission to Treat

I authorize the licensed physical and/or occupational therapists at STEP UP Physical Therapy to provide me with evaluation and treatment.

Assignment to Pay Benefits and Medical Information Release

I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment (Physical and Occupational Therapists of STEP UP Physical Therapy, PLLC).

New Patient Agreement - Out of Network

We accept insurance with out of network benefits.

Amount covered is dependent on your plan. Please enter your coverage amounts below.

Billing policy for therapy: We will bill your insurance plan for services rendered.

Important: This is not a guarantee of payment for services. This is strictly a description of your benefits for outpatient physical and/or occupational therapy. If you do not feel this benefit is correct, please contact your insurance company. Ultimately, you are responsible for ANY amount not covered by your insurance company.

Please read the following information:

• Your insurance policy is a contract between you and your insurance company. We will bill your insurance company on your behalf. Any amount not covered or denied by your insurance company is your responsibility. If your insurance company has not made payment on your account within 90 days, you must pay your account in full or make arrangements for a payment plan. You may then contact your insurance company for reimbursement. Should your account be sent to collections, we reserve the right to charge interest on the overdue balance in the amount of 21% as approved by law.
• We cannot bill your insurance company unless you give us your current insurance information. Please notify us of any changes. In the event your insurance company changes and we are not a participating provider, you may be responsible for these charges.
• Payment is due at time of service for any cash pay service. Once your insurance company has processed your claim, any remaining balance is your responsibility to be paid within 30 days of billing date. In the event that your insurance policy changes and we are not a participating provider, you may be responsible for these charges.
• Cancellation/appointment policy: Unless you cancel at least 24 hours in advance, our policy is to charge $50.00 per missed appointment. This will allow us to fill your appointment slot with someone who may need care urgently. Your insurance company will not cover missed appointment fees.

By signing below I understand and agree to this Financial Policy and acknowledge I have read the notice of privacy practices.

Permission to Treat

I authorize the licensed physical and/or occupational therapists at STEP UP Physical Therapy to provide me with evaluation and treatment.

Assignment to Pay Benefits and Medical Information Release

I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment (Physical and Occupational Therapists of STEP UP Physical Therapy, PLLC).