Upon referral from a physician, Physical and Occupational Therapy services are provided in this clinic by a licensed Physical or Occupational (Hand) Therapist. These services are billed separately from the physician’s services, with charges that are specific to Physical or Occupational Therapy. Physical Therapists and Occupational Therapists are required to conduct their own independent evaluation and establish a plan of care in order to bill for their services. After treatment has been initiated, some follow-up treatment may be administered by a licensed Physical or Occupational Therapy Assistant. These assistants are supervised by a therapist. Billing for these services will be under a therapist name. Note that the therapist listed on your bill may not be the therapist who treated you but the therapist who was present to supervise at the time of your treatment.

Billing Statements: You will be billed for a Physical Therapy or Occupational Therapy evaluation in addition all therapy treatment you have receive. You may incur additional charges for specific supplies provided for use at home. Not all supplies are covered by the insurance. If you receive both Physical AND Occupational Therapy, there will be separate charges for each.

Co-pays: Some insurance plans require a separate co-pay and/or deductible for Physical/Occupational Therapy. If you have a co-pay for your doctor’s visit, it is possible that you will have a co-pay for Therapy services. Co-pays are due at the time of service.

Prior to Your Next Therapy Appointment: If you are scheduled for follow up therapy services after your initial evaluation, it is your responsibility to check with your insurance company/ work comp carrier regarding therapy coverage, limitations and co-pays. If you have had therapy services performed with another therapy group within this calendar year, it may affect your remaining therapy benefits.

Benefits and Prior Authorization: Some insurance plans have limitations on the number of therapy visits they will allow per calendar year. It is your responsibility to find out the number allowed in your plan. For instance, some plans only allow 20 therapy visits per calendar year (additional visits would require an authorization). If you have had any therapy services this year (even if not for your current problem), it is imperative that you inform the Therapy team. If your insurance denies payment for lack of prior authorization, the cost of treatment will become your responsibility.

Treatment initiated without a Physician Referral: Physical Therapists in Minnesota are permitted to initiate therapy without a physician referral however most insurance policies require a physician referral. If you choose to have treatment without a physician referral, Viverant will bill your insurance company however your health insurance may deny payment for the therapy. In this event, the cost of treatment will become your responsibility.

I have read and understand the above statement. I understand that I will be responsible for any and all charges regarding Physical and/or Occupational Therapy that are not covered by my health insurance or workers compensation benefits.