Optimum Health and Wellness

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?
    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)


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Signature Certificate
Document name: Financial Agreement
lock iconUnique Document ID: b9bb143ba1a4d2cbd4013835e8272bf48854055e
Timestamp Audit
January 27, 2020 10:58 am AKDTFinancial Agreement Uploaded by Optimum Health and Wellness - emily@ohwpt.com IP
June 8, 2020 3:31 pm AKDTNikki Brown - nikki@ohwpt.com added by Christopher Comstock - emily@ohwpt.com as a CC'd Recipient Ip:
August 28, 2020 9:38 am AKDTNikki Brown - nikki@ohwpt.com added by Optimum Health and Wellness - emily@ohwpt.com as a CC'd Recipient Ip: