Our office is pleased to accept your insurance assignment. After verification of coverage we will file your claim forms and assist you in every way we can. However, it must be fully understood that the contract is between you and your insurance company, and you are fully responsible for any amount not paid by your insurance company. Our office does not guarantee that your insurance company will pay. We will make every attempt to verify your insurance coverage. However, if your insurance claim is for some reason denied, you are responsible for the full amount of the bill. We will not begin a dispute with your insurance company over your claim. That is your responsibility and obligation.
I hereby authorize Victorious Therapy Services to apply for benefits on my behalf for covered services rendered by this office. I request that payments from my insurance be made directly to Victorious Therapy Services. Should an insurance payment inadvertently be sent to me, I will endorse it and forward it to Victorious Therapy Services immediately. I understand that the card I have put on file may be charged for any balance unpaid by the insurance company, including deductibles and coinsurance that is unpaid. I agree to pay copays and any unmet deductible at the time of my appointment. I certify that the information I have reported with regard to my insurance is accurate. I permit a copy of this authorization to be used in place of the original. I may revoke this authorization at any time by form of written request.