690 E. Warner Rd. Ste. 105, Gilbert, AZ 85296 || Phone: (480) 820-6366 || Fax: (480) 820-0462
Check here if patient has DDD, DDD patients still need their primary and secondary insurance listed above:
I understand and agree that I am ultimately responsible and liable for payment of all charges assessed for professional services rendered and will pay any sum due upon demand. I understand that insurance claim forms will be submitted to my insurance company as a courtesy. I understand that verification of benefits IS NOT a guarantee of payment by the insurance and only done as a courtesy. Please be aware that some insurance companies require that payments for therapy services issued directly to the insured member and not to the provider. Please ensure all checks received are signed over and sent to ATS upon receipt. If an insurance check is cashed accidentally, a personal check will need to be issued to ATS.
I understand and agree that if it becomes necessary to retain an attorney and/or collection agency for the collection of any outstanding charges, whether a lawsuit is filed on my account, I will be responsible for any attorney and/or collection fees and court cost in addition to outstanding balance. Patients authorized for therapy by the Arizona Department of Economic Security, Division of developmental Disabilities, are not responsible for payment of charges.
If you need to cancel an appointment, we request a 24-hour notice. If you cancel within less than 24-hours of your schedule appointment time, you will be charged $35.00. The insurance will not pay for “no shows” or late cancellation charges – theses charges must be paid by the patient by or upon the following session.
I request that payment of authorized insurance benefits on my behalf go to Advanced Therapy Solutions.
I hereby authorize the release of any information, including the diagnosis and the records of any treatments or examinations rendered, to my insurance company or companies or other health care agencies. I also authorize the release of medical records or copies of such and request that they be transferred to Advanced Therapy solutions, 690 E Warner Road Suite 105, Gilbert, Arizona 85296.
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