Common Contracts
2 similar Disclosure Agreement contracts
DISCLOSUREDisclosure Agreement • May 18th, 2022
I, the above patient, parent or legal guardian of the patient, or policyholder as applicable hereby contract with Connecticut Physical Therapy Specialists, LLC (CTPTS) to render physical therapy as prescribed by my physical therapist and/or my referring physician. I understand and agree that CTPTS will first seek reimbursement from my insurers and I direct my insurance to pay all benefits or coverage to which I am entitled to CTPTS and I hereby assign any benefits or coverage to which I am entitled to CTPTS for their services. I understand and agree I am responsible for all co-pays, co-insurance, deductibles or any fee, charge or service my insurer does not pay. If an insurer reimburses me directly, or my portion of a settlement, I will immediately remit to CTPTS the share of reimbursement they are entitled for their services. If I have no insurance I understand and agree I am responsible for all fees, charges or services rendered by CTPTS.
DISCLOSUREDisclosure Agreement • May 31st, 2021
I, the above patient, parent or legal guardian of patient, or policyholder as applicable hereby contract with Connecticut Physical Therapy Specialists, LLC (CTPTS) to render physical therapy as prescribed by my physical therapist and/or my referring physician. I understand and agree that CTPTS will first seek reimbursement from my insurers and I direct my insurance to pay all benefits or coverage to which I am entitled to CTPTS and I hereby assign any benefits or coverage to which I am entitled to CTPTS for their services. I understand and agree I am responsible for all co-pays, co-insurance, deductibles or any fee, charge or service my insurer does not pay. If an insurer reimburses me directly, or my portion of a settlement, I will immediately remit to CTPTS the share of reimbursement they are entitled for their services. If I have no insurance I understand and agree I am responsible for all fees, charges or services rendered by CTPTS.
