Get Self Pay Rate Agreement - Precision Physical Therapy

Filling out the Self Pay Rate Agreement at Precision Physical Therapy is an essential step for patients opting for self-payment. This guide provides clear, step-by-step instructions to help users complete the agreement online efficiently.

Follow the steps to complete your Self Pay Rate Agreement.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Review the payment information specified in the agreement. The self-pay rate is $120 per visit, which needs to be paid prior to treatment. Ensure you understand the payment methods accepted, including cash, check, or credit card.
3. Read the disclaimer carefully. This section outlines your responsibilities regarding payment and your choice not to use a private insurance company. Acknowledge that you accept any legal and financial implications of this decision.
4. Sign the agreement in the designated space to confirm your understanding and agreement to the terms. This includes writing your signature and the date of signing.
5. Print your name clearly in the space provided to ensure correct identification.
6. Once all sections are complete, review the document for accuracy. Ensure that you have filled in all required fields before finalizing.
7. After reviewing, you can save changes, download, print, or share the form as necessary to proceed with your treatment.

Complete your Self Pay Rate Agreement online today to ensure a smooth and efficient process.