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:
Name of Insurance Company Policy Number Secondary Company Policy Number
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
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Financial Agreement
Agree & Sign