Workers' Compensation: If you have an active Workers' Compensation number and you are expecting bills to be paid by Workers' Compensation (WC), we will send the appropriate forms, reports, and bills to your WC carrier providing we have a letter from your referring physician, your attorney, or WC carrier verifying your WC number and the acceptance of your case.

Automobile and Litigation Cases: Payment is expected at the time of the services, including evaluation and treatment. Your records can only be relased after payment has been received.

Self Pay: Payment in full is expected at each visit. You will be given a copy of your bill, if needed, to submit for reimbursement. We accept cash, personal checks, or credit cards. There is a $25.00 fee for any returned checks.

Reports and Forms (life insurance, disability, social security, etc.): Reports will be furnished on request at the completion of course of treatment. This request must be in writing and must specify to whom and where the report should go. Please request a Records Release Form for this purpose. We require a standard $15.00 fee, payable in advance, to cover administrative costs for preparation of medical reports. A nominal fee may be charged for filling out lengthy insurance or disability forms.

Appointment Cancellation: Should you find it necessary to cancel your appointment, we require that we be notified 24 hours in advance. If adequate notification of cancellation is not made, you, not your insurance carrier, will be charged for the missed appointment. The fee for this is $65.00 per visit, no exceptions. We reserve the right to drop your appointment if two scheduled appointments are missed without proper notification. Your physician and/or insurance carrier will be informed of the missed appointments. In order to insure continuous treatment, please be present and punctual for all appointments.

Collection Proceedures: Collection procedures will begin after the following conditions have occurred and you refuse or are unwilling to pay the outstanding balance.

1.) All efforts have been exhausted to collect reimbursement from your insurance carrier.

2.) Denial of any and/or all claims for reimbursment of services performed by Rehab At Work by your

insurance carrier.

3.) Misreprentation or misleading statement by you the patient as to the exact nature and cause of your

injuries that Rehab At Work has treated, as they specifically relate to automobile accidents and

worker’s compensation cases.

4.) Accounts that are over 120 days old.

Collection procedures will be initiated either in writing or verbally on any account that has meet these conditions or upon the judgement of the finance manager. There will be an additional 35% charge on the total outstanding balance on the account, if the account is placed with our contract collection agency. These additional fees pay for any collection fees, attorney’s fees and other related expenses associated with the collection of any account.

I, the undersigned, hereby agree to abide by and adhere to these policies. I also agree that in the event of default in the payment of any amount due, if this account is placed in the hands of an agency or attorney for collection or legal action, to pay any additional charges equal to the cost of collection, permitted by laws governing these transactions. It is agreed and understood that payment by the responsible party (you the patient) will not be delayed or withheld because of any insurance coverage or the pendency of claims.

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