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Section 5: Review Our Policies

Please take your time reading through our policies at Borja Physical Therapy.

Client Authorization And Responsibility

I hereby consent to treatment at Borja Physical Therapy PLLC. By consenting to treatment I authorize, on behalf of any covered family member or myself, direct billing of my insurance company and direct payment to Borja Physical Therapy PLLC. By consenting to treatment, I also consent to the release of necessary medical information needed for the processing of the insurance claims, including release to any entity for the continuation of my medical care.

I understand that a photocopy of the release is as valid as the original. In the event that my insurance company does not pay or partially pays on behalf of any covered family member or myself, I understand that it is my financial responsibility to remit payment in full to Borja Physical Therapy PLLC upon completion of the treatment sessions or within 30 days thereafter.

I further understand that if the matter is referred to an attorney for collection, I will be responsible for the attorney’s fees and court costs.

Notice Of Privacy Practices

I hereby authorize that I am aware of my rights as it pertains to HIPAA and my Protected Health Information (PHI). Borja Physical Therapy has offered me a copy of their Notice of Privacy Practice for my own records.

You may see our privacy practices at: borjapt.com/privacy-notice/ or request a copy from our Customer Service desk.

Financial Policy

We are pleased and honored that you and/or your referring physician have trusted us with your care. We hope that after your first visit you will feel valued and well taken care of.

Physical Therapy is a tool, a pathway to get you to your goals. Our highly trained staff members at Borja Physical Therapy strive to do their best to make your experience pleasant. As part of this relationship, we wish to review expectations of your financial responsibility as outlined in our Financial Policy.

Please Read The Following Information Carefully:

Insurance benefits are checked by the Borja Physical Therapy Billing Department as a courtesy to the patient. Please provide insurance cards upon first visit to ensure that claims are submitted promptly. If you cannot pay upfront, the billing department may be able to work with you to set up a payment plan. In the rare case the insurance denies claims because information needs to be verified by you, the balance will be shifted to you until the issue is resolved with your insurance company. If you are unwilling to call the insurance company to give that required information, you will be responsible for the entire amount of the bill.
If you have previously received services from the provider (Borja PT) and wish to return to physical therapy and still have a remaining balance on file, you must pay off the remaining balance in full or enter into a payment plan agreement with the provider (Borja PT) in order to begin treatment. As previously stated, the Borja PT Billing Department may work with you to create a payment plan based on the remaining balance in question.
It is important to understand that the patient is under contract with their own insurance company. The amount owed to the provider (Borja PT) is 100% determined by the patient’s policy. The amount owed to the provider (Borja PT) is never determined by Borja PT. This includes unmet deductibles, co-pays, or co-insurances. In general, it is not acceptable for a patient not to pay the amount owed to the provider (Borja PT) because it is a breach of the contract with the patient’s insurance company. In addition, Borja PT is in contract (in network) with most insurance companies and therefore, where applicable, will write off anything over what is allowable by contract. Billing is done on a daily basis to all insurance companies.
Please do not ask the billing department to adjust off any charges, deductibles or co-pays over what is allowed by insurance as it is generally not permitted for them to do so. It is VERY important for the patient to take responsibility in knowing his/her individual benefits and what insurance will allow so unexpected balances do not occur. The Borja PT Billing Department files with many insurances and most offer several different plans, therefore it is the patient who must make sure the benefits checked are what match their plan.
In the case the patient needs a service that is not covered by the in network agreement, Borja PT will notify the patient to see if the patient agrees to the service. The billing department will then make arrangements to charge and bill the patient accordingly.
If you do not have In-Network Medical Insurance, please speak with our billing coordinator to discuss self-pay options. Please note: There is no payment plan option for our self-pay patients.
Third Party/Workers Comp/MVA Patients: We are happy to see personal injury or motor vehicle accident patients. The billing department will need information such as claim number, adjuster’s name and contact phone number and mailing address. Should the Third Party/Workers Comp or MVA company deny our claims; the claims will be submitted to your Medical Insurance or become your responsibility. Please let us know if you have an attorney involved along with his/her name and phone number.
Minors and Dependents: Parents and guardians are responsible for payment for their dependents at the time service is rendered.
Billing statements are sent to patients with a personal balance on a monthly basis. We ask that upon receipt of such statement, payment is sent to our office within thirty (30) days of receipt. If you have a financial hardship or you are unable to pay the balance in its entirety, please contact our billing coordinator to discuss payment options. If your account becomes delinquent and you have not established or met payment options with our billing office, your account will be turned over to our outside collection agency and your account will be assessed a $25.00 collection fee.
We look forward to providing you with world class physical therapy services!!

Signing below indicates you understand and agree to the terms of this policy.

No-Show / Cancellation Policy

We realize that emergencies and other scheduling conflicts arise and are sometimes unavoidable, however, advance notification allows us to fulfill other clients scheduling needs and keeps the clinic operating at its most efficient level.

We strive to promote a higher quality of care at Borja PT, and as such, missed, or late appointments are a significant disruption to the clinic, your physical therapist and other patients.

Please Read The Following Information Carefully:

Please provide our office with 24-hour notice to change or cancel an appointment. Clients who do not provide 24-hour notice to change a scheduled appointment may be responsible for a $15.00 cancellation charge. Clients who do not attend a scheduled appointment may be responsible for a $25.00 no call/no show charge. These charges cannot be billed to insurance and must be paid on or before the next scheduled appointment.
We reserve your appointment time just for you. We do not double-book our clients so that we may provide optimum treatment outcomes. The 24-hour notice allows us to place another client in your canceled appointment period.
Your treatment plan has been established by you and your practitioners to help you to get you back to your regular activities as quickly as possible. Missing appointments hinders that process and may end up prolonging recovery.
Certain accident claims adjusters and application for disability will require regular attendance to physical therapy as a requirement of an approved treatment plan. If appointments are missed or canceled on a regular basis it could affect the status of your claim.
After missing two appointments without notice, you may be placed on a same day scheduling policy for your treatments, which would not allow you to schedule any appointments in advance.

Thank you for providing our office and our patients with this courtesy.

Your Signature
Please sign your full name below, indicating that you've fully read, understand and agree to the policies:

Your Signature:* *

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*Note: If you are under the age of 18, a parent or guardian will need to sign this document on your behalf.

Section 1: Your Basic Information

Section 2: Your Current Injury or Condition

Condition Specific Questions

Functional Limitations

Revised Oswestry Questionnaire

NDI Questionnaire

SPADI Questionnaire

UEFI Questionnaire

LEFS Questionnaire

Medical History

Imaging & Testing

Section 3: Pre-screening Questions

Section 4: Required Document Information

File Upload: Health Insurance Card

File Upload: Script

Health Insurance Information

Script Information

Health Providers Information

Auto Insurance Information

Workman's Compensation Information

Section 5: Review Our Policies

Client Authorization And Responsibility

Notice Of Privacy Practices

Financial Policy

No-Show / Cancellation Policy