Common Contracts
2 similar Outpatient Therapy Treatment Agreement contracts
OUTPATIENT THERAPY TREATMENT AGREEMENTOutpatient Therapy Treatment Agreement • August 1st, 2013
Name of Primary Insurance Company: Insured’s ID Number _ Group Number Plan Name and/or Plan ID Number: Cardholder Date of Birth / /
OUTPATIENT THERAPY TREATMENT AGREEMENTOutpatient Therapy Treatment Agreement • August 1st, 2013
FINANCIAL RESPONSIBILITY: I hereby guarantee payment of therapy services to East and West Physical Therapy, LLC and acknowledge receipt of the fee schedule. I understand I am responsible for payment of my account and this facility does not accept responsibility for negotiating a settlement on a disputed claim. All balances, after maximum insurance payment has been received by the facility, are due and payable upon receipt following the last insurance monies received by the facility. Interest of 1.5 % monthly will be added to all accounts that become 30 days past due. In the event this account is placed with an attorney or collection agency for collection, the undersigned agrees to pay reasonable attorney’s fees, legal expenses and lawful collection costs in addition to all other sums due hereunder. X Initial
