NEW PATIENT FORMS AND POLICIES
For your convenience, we have provided our patients forms on our website. Please download the forms and fill them out no more than 48 hours (in order to accurately assess your condition) prior to your initial evaluation and bring the forms with you along with your Health Insurance Card(s), medications list (including dosage/frequency/method of administration) and Prescription for Physical therapy when you come in for your initial appointment. If you choose to fill out the patient forms at our office, please arrive 15 minutes before your appointment to allow enough time to get them completed.
Please feel free to email at firstname.lastname@example.org or call us if you have any questions and/or require assistance.
Our friendly staff will gladly assist you.
Your Right to a “Good Faith Estimate”
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
Make sure to save a copy or picture of your Good Faith Estimate.
For additional information, visit www.cms.gov/nosurprises.
New paperwork to be uploaded by NSPT no later than 12/10/2020. Pardon for the inconvenience.
Authorization to request imaging report(s)
Medication List, COVID-19 checklist, Past Medical History and Surgery
(please bring your medication/vitamins/minerals/suppliments list to your initial appointment)
Our forms are PDF files.
To download and print the forms, you'll need the free Adobe Acrobat Reader program.
PATIENT PAYMENTS AND CANCELLATION POLICY
Co-pays, Deductible, and Co-Insurance are per visit and due at the time of each appointment.
Our Biller will do her best to help you understand your payment structure. However, it is the patient’s responsibility to know what their benefits are and what their payment per visit will be.
North Shore Physical Therapy is NOT responsible for any inaccurate estimates made.
WE REQUIRE 24-HOUR NOTIFICATION FOR APPOINTMENT CANCELLATIONS
At North Shore Physical Therapy, we are proud of our one-on-one treatment approach; we never double-book patients. This approach allows our patients to have the Therapist’s constant undivided attention. With proper notification, most cancelled appointments can be easily filled. However, with less than 24 hours notice it is difficult to fill the vacant time slots created by cancellations.
Effective June 1, 2017, we assess a $30 fee for appointments missed or cancelled with less than 24 hours notice.
We reserve the right to offer your slot to another patient if you are 15 min late and have not notified the office.
Patients who miss appointments or cancel with less than 24 hours notice three (3) times will have their future visits removed and will not be allowed to schedule ahead. Those patients may call on any day to see if there is an available time slot with their Therapist.
We never penalize cancellations with more than 24 hours notice.
Thank you for choosing North Shore Physical Therapy