STEP 3

Stafford physical therapy policy agreement

Please feel free to Contact Us with any additional questions or concerns.

Responsibility of payment

I understand that I am responsible for paying all charges (e.g. Copays, Cost shares, Deductibles, and entire bill if insurance will not cover the claims at all) as well as any interest, Collection fees, Cancellation / No Show fees, penalties and attorney’s cost if the need arises.

Insufficient funds

Should I present a check that is unable to be processed due to insufficient funds, I understand that a $50.00 fee will be assessed. The replacement funds are to be in the form of: 1. Cash, 2. Money Order, 3. Cashier’s Check, 4. Credit Card. Should your account go to collections for an outstanding balance, there will be a fee of 35% of the outstanding balance added to your account.

Cancellation / no show policy

I understand that if I need to cancel, I will call 24 hours before my scheduled appointment. If I fail to do so, I understand there will be a $25 fee added to my account. I also understand that I need to call if I am running late. Stafford Physical Therapy staff will do their best to accomodate up to 15 minutes late. After 15 minutes, I understand that my appointment will count as a cancel / no show and the fee will be applied to my account.

Assignment of benefits

I hereby assign Stafford Physical Therapy medical benefits otherwise payable to me or my insured dependent by virtue of medical insurance obtained at Stafford Physical Therapy.

RELEASE OF INFORMATION

I authorize Stafford Physical Therapy to release my insurance compan(ies) or other third-party agencies, whatever information necessary in connection with payment of medical services.

VALIDATION

It is my understanding that I am to pay the agreed upon copay and / or payment arrangement as set by my insurance plan and / or Stafford Physical Therapy on a weekly basis unless other arrangements have been made.

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STAFFORD

572 Garrisonville Road, Stafford, Virginia 22554

FREDERICKSBURG

1206 Bragg Road, Fredericksburg, Virginia 22407

About US

Stafford Physical Therapy is a family-owned and operated physical therapy clinic that’s served patients in the Fredericksburg, Spotsylvania and Stafford region since 1987.

NAVIGATION