I authorize Family Physical Therapy and Wellness, LLC and its billing agency to bill my insurance company directly for
the covered portion of charges, and I authorize payment of benefits directly to Family Physical Therapy and Wellness,
LLC. I authorize Family Physical Therapy and Wellness, LLC and its billing agency to release medical or other
information necessary to process this claim. I understand that I am responsible for my physical therapy charges, and
I agree to pay my deductible, my co-insurance or co-payment, and any charges not reimbursed by my insurance carrier.
I understand that some insurance companies require medical or administrative pre-authorization for treatment, or have
reimbursement limits on physical therapy treatments. I understand I am responsible for knowing and meeting the
requirements for my insurance plan.