Our Financial Policy
Thank you for choosing Quality Rehab Solutions. We are honored to have the privilege of serving you. The following is a statement of our Financial Policy which we require you read and sign prior to treatment. All patients must complete our information and insurance forms before seeing a therapist.
FOR YOUR CONVENIENCE, WE ACCEPT CASH AND ALL MAJOR CREDIT CARDS
You have indicated that it would create a financial hardship for you to pay our standard fee for service. In consideration, you will receive a discount, provided payment is received at the time service is rendered. No forms will bee produced now or in the future for you to submit for insurance billing.
We are obligated legally to accept payment from your workers’ compensation carrier as payment in full if your claim is accepted by your plan. In the case that they refuse to pay, you will be responsible for payment in full.
If your treatment is being covered by liability or auto insurance, the insurance company may not pay until the case is settled. At the beginning of your course of treatment, please provide us with your attorney and health insurance information, if applicable. If neither are provided, we require a monthly good faith payment of $100.00.
RELEASE OF INFORMATION AND CONSENT TO TREATMENT:
1. I consent to be treated at Quality Rehab Solutions. 2. I authorize Quality Rehab Solutions to request any information regarding illness, injury, medical history, treatment or copies of medical records from other healthcare providers.
3. I authorized Quality Rehab Solutions to release any information requested by my insurance company, other healthcare providers, or my attorney, regarding my medical history, treatment, evaluation or any other subject history.
4. I authorize and instruct my insurance company to make checks payable to Quality Rehab Solutions and mail directly to 7362 McLaughlin Rd. Peyton, CO 80831.
5. I acknowledge that I have been provided with a copy of the Patient’s Notice of Privacy Practices.