I authorize that the payment of my insurance benefits be made directly to Base Physical Therapy, PLLC for all services delivered; if I am paid directly I will promptly pay Base Physical Therapy, PLLC all monies paid to me. I understand and agree that all health and accident policies are an arrangement between an insurance carrier and myself, and that all payments designated “the patientʼs responsibility” (ie deductibles and co-insurances) are due and payable at the time of service or statement receipt. I guarantee I will
pay the amount deemed “my responsibility” by my insurer by the statement due date. I certify that all the information I have provided Base Physical Therapy, PLLC for payment, including, but not limited to, related accidents, illnesses or other insurers is accurate and truthful. I authorize Base Physical Therapy, PLLC the ability to release information needed to substantiate payments for care to insurance carriers and all others financially liable for my care. I understand the policies of Base Physical Therapy, PLLC.