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Financial Agreement

As a courtesy to our patients, insurance claims are filed directly with the Insurance carriers. Our office will normally assist you to the best of our ability by contacting and verifying your eligibility for medical benefits. Verification of eligibility and benefits does not guarantee payment for all services provided. Ultimately you are responsible for knowing/understanding your benefits, policy coverage, limitations, and exclusions, and for paying the balance on your account. Please review the explanation of benefits you receive from your insurance company and note what services are covered or non-covered and what is patient responsibility. It is your responsibility to know your insurance benefit plan and notify the therapist of any services that are not covered and discuss other treatment options. OHWPT, Inc. is NOT responsible for incorrect information passed on to us by your insurance company.

I agree and attest to the following:

I understand that I am financially responsible, NOT my insurance company, to pay my no-show/cancellation fees. (please initial )
I hereby authorize and assign OHWPT, Inc. and/or its affiliates any and all benefits of payments for services rendered under terms of my insurance policies, and hereby individually obligate the payer to pay the account to OHWPT, Inc. and/or its affiliates in accordance with the standard and customary charges incurred during my period of treatment. (please initial )

Name of Insurance Company Policy Number
Secondary Company Policy Number
Do you have Medicare? Yes No

If Medicare is filed, I authorize the release of any medical information or other information necessary to process claims. (please initial )
I agree to notify this office of any changes in my insurance status or the information given on this date. I understand that failure to provide updated information may result in denial of payment and will become my financial responsibility. (please initial )
I understand that obtaining prior authorization and verification of eligibility and benefits does not guarantee payment and that I am ultimately responsible for all out-of-pocket expenses which may include but are not limited to co-pays, coinsurance, deductibles, non-covered services, no-show/late cancellation fees, and that balances are due at the time of service. (please initial )
I understand that even if I have secondary insurance, I may still be responsible for balances due as dictated by primary insurance if secondary insurance does not pay. (Medicaid is the exception) (please initial )

By signing this authorization form I acknowledge that I have fully read or had this form read and/or explained to me, and that I fully understand its contents. I have been given ample opportunity to ask questions, and any questions have been answered satisfactorily.

Parent/Legal Guardian or Representative (If Applicable)
Date

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Your legal name

Your email address

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Timestamp

Audit

January 27, 2020 10:58 am AKST

Financial Agreement Uploaded by Jaimee Watson - jaimee@ohwpt.com IP 206.223.197.206

June 8, 2020 3:31 pm AKST

Nikki Brown - nikki@ohwpt.com added by Christopher Comstock - emily@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206

August 28, 2020 9:38 am AKST

Nikki Brown - nikki@ohwpt.com added by Optimum Health and Wellness - emily@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206

July 1, 2021 4:31 pm AKST

Stephanie Cain - stephanie@ohwpt.com added by Optimum Health and Wellness - nikki@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206

July 9, 2021 5:07 pm AKST

Elizabeth McCallister - elizabeth@ohwpt.com added by Optimum Health and Wellness - nikki@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206

February 4, 2022 12:36 pm AKST

Elizabeth McCallister - elizabeth@ohwpt.com added by Optimum Health and Wellness - jaimee@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206

March 15, 2022 10:56 am AKST

Elizabeth McCallister - elizabeth@ohwpt.com added by Optimum Health and Wellness - elizabeth@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206

March 15, 2022 10:56 am AKST

Jaimee Watson - jaimee@ohwpt.com added by Optimum Health and Wellness - elizabeth@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206

March 30, 2022 8:27 am AKST

Elizabeth McCallister - elizabeth@ohwpt.com added by Optimum Health and Wellness - elizabeth@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206

March 30, 2022 8:27 am AKST

Jaimee Watson - jaimee@ohwpt.com added by Optimum Health and Wellness - elizabeth@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206

May 31, 2022 3:30 pm AKST

Annie Morris - annie@ohwpt.com added by Optimum Health and Wellness - elizabeth@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206

May 31, 2022 3:32 pm AKST

Document owner elizabeth@ohwpt.com has handed over this document to jaimee@ohwpt.com 2022-05-31 15:32:05 - 206.223.197.206

May 31, 2022 3:32 pm AKST