I authorize that the payment of my insurance benefits be made directly to Spero Rehab for all services delivered. If I am paid directly on accident, I will promptly pay Spero Rehab all monies paid to me. I further authorize the release of any medical or other information pertinent to my case to any insurance company, adjuster, or attorney involved in the case for the purposes of processing claims and securing payment of benefits.
I understand that all payments designated as "the patient's responsibility" such as co-insurances and deductibles 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 the information I have provided Spero Rehab for payment including, but not limited to related accidents, illnesses or other insurers is accurate and truthful.
We have a strict CANCELLATION POLICY. We must be notified within 24 hours of your appointment if you choose to cancel. We have very limited space on our schedule due to high demand so for the well-being of all of our patients we must enforce this. This fee is $60.
If you are more than 30 minutes late to your treatment session without calling you will be charged a late fee of $30.
Returned check charge of $35 and all future payments must be made with check or credit card.
There is a $25 medical records fee if you would like (or any requesting party would like) a full copy of your medical chart.
We check your therapy benefits as a courtesy to you. It is ultimately your responsilbity to know what is your financial responsibility and what your visit limits are. If these are exceeded for any reason you will be held financially responsible. We do work directly with your insurance company so we will help you keep track.
If I chose to release my medical records (specified below) I understand the following:
This authorization does not expire. If you do choose to change your disclosure choices you can do so in writing.
Spero Rehab is not responsible for the redistribution of medical records after they are released from our care per your instruction.