Patient Registration Form

Elkins Physical Therapy & Sports Injury Clinic – Elkins, WV

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  • FINANCIAL POLICY

    Payment is expected at the time of service, unless you have medical insurance. In that case, we will bill that company directly. Ultimately you are responsible for any expenses incurred, including charges denied, those applied to deductibles, or balances not picked up by secondary insurance.

    Co-payments and deductibles are due at the time of service.

    MEDICAID is limited to 20 treatments per year.

    MEDICAL RELEASE

    I request that payment of benefits be made on my behalf to Elkins Physical Therapy and Sports Injury Clinic (EPTSIC) for any services furnished by them. I authorize release to the Health Care Financial Administration and its agents any medical information needed to process this claim.

    PRIVACY OF PATIENT HEALTH INFORMATION

    I received a copy of Elkins Physical Therapy & Sports Injury Clinic’s Notice of Privacy Practices as required by HIPAA.

    I have read and understand the information in the financial policies and medical release.

    ATTENDANCE POLICY

    Please notify our office 24 hours in advance if it is necessary for you to reschedule an appointment. In such a case, please call our office and arrange for a make-up appointment. The make-up appointment needs to be in the same week, preferably the very next day.
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