Ankeny Intake Form

Financial Policy

Thank you for choosing Integrated Physical Therapy & Sports Medicine, PLLC as your physical therapy provider. We will work closely with you and your physician to provide you with treatment. Please understand that timely payment relationship.

for our services is important. Your clear understanding of our financial policy is important to our professional Our Financial Policy is as stated:

Cancellation/No Show Policy: A 24-hour notice must be received or a fee of $50.00 will be incurred. (Please refer to our policy below).

All copays are due at the time services are rendered.

a. If you have a deductible to meet, you will be billed for the services rendered: first through our billing entity Medical Billing services.

b. The balance on your account after the deductible has been met and coinsurance has been applied. will then be your responsibility to pay.

If any portion of your account exceeds 60 days you will become responsible for this amount, PLUS interest at

1½% per month, regardless of your insurance.



If payment arrangements need to be made, you will need to contact our billing entity: Medical Billing Authority at 515-963-9464.

Our billing entity, Medical Billing Authority, cannot keep a card on file for you to pay your balance/copays.

However, Integrated Physical Therapy can. If this is an option you would like to consider, please arrange this with our front office staff.

Motor vehicle accident patients: please discuss payment/policy with front office staff. - Thank you.

If you have medical insurance, LEGALLY we must submit claims for visits through your insurance.

If you do not have medical insurance, our self-pay rate for treatment visits is $130.00 for initial evaluation and $100.00 a visit thereafter.

Should your account be referred to collections, you will be responsible for the costs of collection, including legal fees.

We accept the following form of payments: cash, checks, and debit/credit cards. We accept the following major credit cards: Visa, Mastercard, Discover, and American Express.

*Please note, if paying by check, a $30 fee will be incurred for returned checks.

Thank you for understanding our financial policies. If you have any questions or concerns, our front office staff will be happy to discuss them with you.

I have read the above and understand that I am financially responsible for payment of services rendered from Integrated Physical Therapy. I understand that after insurance is billed, it is my responsibility to pay the balance due after.

NO SHOW / CANCELLATION / RESCHEDULE POLICY



If you DO NOT SHOW UP to your scheduled appointment, a $50.00 no show charge will be incurred on your account.

If you arrive 10 or more minutes late to your scheduled appointment, you may be asked to reschedule to a later time that same day. (May be with a different PT, or a different day).

If you cancel your appointment less than 24 hours prior to your scheduled appointment, you will incur a $50.00 cancellation charge on your account.

If you cancel your appointment more than 24 hours in advance, you will NOT incur any fees.

Your insurance will NOT cover these fees and it is your personal responsibility to pay these fees on your account.

If an email address is given upon patient registration, an email appointment reminder will be sent the day before. If you would like to have text appointment reminders, please notify the front desk. A printout of your schedule can also be given to you at the time of scheduling.

To effectively manage our therapist schedule and your physical therapy care, it is your responsibility as a patient/guardian to a minor, to call or email the office to let us know about the need for cancellation or rescheduling of appointments. A message may be left on our voicemail as well.

We understand that situations come up (sick children, transportation issues, etc.) but understand that when these appointments are cancelled within the same day, it may not be possible to fill your appointment time and a fee on your account may be incurred. If you have any questions regarding these policies, please don't hesitate to discuss this with your physical therapist or the front desk staff.

Thank you for your understanding of these policies!

By signing below, you as a patient/guardian of a minor understand our cancellation / no show / rescheduling policy and have had any questions or concerns answered.

Insurance Policy

Your medical insurance is a contract between you and your insurance company. We are not a party to this contract. Integrated Physical Therapy and Medical Billing Authority will submit all claims for charges to your insurance provider as a service to you. If your policy requires a referral, please be sure and have it with you when you come to the office and provide this upon registration to the front office staff. Failure to obtain and present this at the time of service may result in a loss of your insurance benefits. If you need assistance in obtaining a referral, please discuss this with your therapist provider.

It is important that you understand your insurance benefits for both you and us as your physical therapist provider. As a courtesy, we will obtain insurance benefits from your insurance provider before you come in (if insurance information is provided), or shortly thereafter. Please be advised that with the changes in insurance occurring frequently, it is ultimately your responsibility to understand your insurance policy. If you have any questions about quoted benefits, please ask our front office staff or your therapist provider or call your insurance provider's number.

It is your responsibility to provide the front office with your insurance card/cards upon check in. If it is not provided, your insurance will not be billed, and you will be responsible for the balance due on your account from services provided to you. If your insurance changes, or you receive a new insurance card, it is your responsibility to let the front office staff know of these changes ASAP, so charges can be billed correctly.

Acknowledgement of Notice of Privacy Practices (HIPPA)

By signing below, you acknowledge that you have been given the opportunity to read the NOTICE OF PRIVACY PRACTICES for Integrated Physical Therapy & Sports Medicine and to have any questions answered before signing.

By signing above, I authorize Integrated Physical Therapy & Sports Medicine to furnish my medical information to my physician, insurance company, and workers compensation insurance by any means necessary. For information released to anyone other than the above, please fill out an extended medical release form (Attorneys, lawyers, and self).

Consent For Treatment:

I hereby authorize and give my consent to Integrated Physical Therapy & Sports Medicine to provide me with therapy services, including, but not limited to, physical and occupational therapy.