I understand that my co-payment and co-insurance will be collected at the time of service unless other arrangements are made.
I also understand that as a courtesy, Build Physio & Performance will check my benefits prior to my first visit (if information received 2 business days prior to first appointment) as well as will bill my insurance carrier.
If any payment is made directly to me for services billed by Build Physio & Performance, I recognize my obligation to promptly submit this amount to Build Physio & Performance. I also understand that if my insurance carrier does not remit payments within 60 days, the balance will be due in full from me.
*I understand the above financial policy and agree to pay the above amount. I understand this is only an estimate and individual insurances may vary. Any differences in collections will be billed or refunded upon receipt of insurance payments.