Visit our Location
2322 Powell St, Emeryville, CA
Give us a Call
(510) 653-5151
Send us a Message
admin@emeryvillept.com
Opening Hours
Mon - Friday: 8AM - 5PM




    THIS IS OUR BEST ESTIMATE. WE CANNOT GUARANTEE THAT YOUR INSURER HAS PROVIDED THE CORRECT INFORMATION.
    **PLEASE NOTE THAT THE EXPLANATION OF BENEFITS WILL PROVIDE THE ACTUAL CO-PAY, CO-INSURANCE AND OTHER PAYMENT DETAILS. IF A DISCREPANCY
    EXISTS, WE WILL DO OUR BEST TO HELP EXPLAIN AND ACCOMMODATE. THIS IS OUR BEST ESTIMATE OF FEES. THANK YOU.

    I. INSURANCE COVERAGE.

    • YOUR INSURANCE HAS STATED THAT THEY WILL COVER YOUR PHYSICAL THERAPY SERVICES AT % AFTER DEDUCTIBLE IS MET OR
      $ CO-PAY.
    • YOU HAVE A DEDUCTIBLE OF $. CURRENTLY, YOU HAVE SATISFIED $ TOWARDS YOUR DEDUCTIBLE.
    • YOU HAVE AN OUT OF POCKET MAXIMUM OF $, WITH $ MET SO FAR.
    • YOUR INSURANCE HAS STATED THEY WILL COVER VISITS PER CALENDAR YEAR. THIS INCLUDES PT, OT, ST, AND CHIROPRACTIC.
      YOU HAVE USED VISITS.
    • MOST INSURERS REQUIRE PHYSICIAN, NP OR PA PRESCRIPTION. WE REQUEST A PHYSICIAN DIAGNOSIS AND PRESCRIPTION FOR TREATMENT.

    II. PATIENT FINANCIAL RESPONSIBILITY.

    • PATIENT IS:
    • PATIENT WILL BE RESPONSIBLE FOR A CO-INSURANCE AMOUNT OF % PER VISIT OR $, NOT INCLUDING ANY
      DEDUCTIBLE THAT HAS NOT BEEN MET OR ANY “UNCOVERED” CHARGES BY YOUR INSURANCE COMPANY.
    • FOR CASH PAY PATIENTS, SESSIONS ARE TO BE PAID IN FULL BEFORE EACH TREATMENT. WE WILL COLLECT:
      A. CO-INSURANCES:
      CO-INSURANCE PAYMENTS INDICATE THE PERCENTAGE AMOUNT YOU ARE RESPONSIBLE TO PAY FOR YOUR TOTAL BILLED VISIT. OUR
      RECOMMENDATION IS TO PAY ESTIMATED CO-PAY SO THAT YOU DO NOT RECEIVE AN ACCUMULATED AND LARGE CHARGE ALL AT ONCE. WE
      ESTIMATE THE LOWER END OF POSSIBLE CHARGES SO THAT YOU DO NOT OVER PAY. IF FOR SOME REASON YOU HAVE PAID TOO MUCH, WE
      WILL ISSUE A REFUND.
      B. CANCELLATION POLICY:
      IF YOU FAIL TO SHOW TO YOUR APPOINTMENT WITHOUT A 24 HOUR NOTICE, YOU WILL BE ASSESSED A $35.00 FEE .

    Patient Signature