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 following payment options:
OPTION A: PAYMENT IN FULL—CASH/CHECK OPTION B: PAYMENT IN FULL—CREDIT CARD OPTION C: CARE CREDIT 800-365-8295No initial paymentTake 12-60 months to pay including minimal financing chargeFixed rate and payments OPTION D: OFFICE PAYMENT PLANBalance to be paid off in 12 months. No financing fee or interest. Monthly payments (NO LESS THAN 10% OF OWED AMOUNT) set up by automatic deduction from VISA/MC/electronic check draft. *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.