Patient Agreement to Financial Policy

 

Payment is due at the time of service. Clients must submit payment in full prior to appointment.

The Dizzy Clinic is out of network with all insurance providers. It is the responsibility of the patient to understand their own insurance benefit i.e.- out of network benefit coverage.  The Dizzy Clinic will provide forms and invoices for submission of request of reimbursement.  

Cancellation/appointment policy: cancellation must be made at least 24 hours in advance of your appointment.  If the appointment is not cancelled in 24 hours you will be responsible for a $20.00 charge.

Permission to Treat: I authorize Physical Therapy to be provided by a licensed physical therapist via videoconferencing on Skype..

By completing and submitting the form below, I understand and agree to the above terms.

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Name
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Date of Birth
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Today's Date