Excel Patient Self-Pay Form

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You have requested that your or your dependent’s physical therapy visits be delivered via telehealth as a “self-pay” service. By signing this form, you are acknowledging that you understand that the Provider will not be billing any insurance carrier for services provided, and that you are subject to the self-pay policies and guidelines of the Provider as listed below.

Please be aware that:

Self-pay services must be paid in full on the date of service.

If you have health insurance that you are electing not to bill for services, you will likely not be reimbursed by your carrier, nor be able to apply these payments towards your deductible.

The Provider will not submit billing to your insurance carrier for previously completed self-pay visits if you choose to revoke your self-pay status at a later date.

Please check all that may apply from the boxes below:

Patient is choosing to receive telehealth services during COVID-19.Patient does not have health insurance coverage.Patient is covered by a contracted insurance company, but does not wish the Provider to submit a claim to my carrier. Instead, elects to pay for all services out of pocket.Therapist/Facility does not participate in my health insurance plan.Service is not covered by my health insurance company.

Patient Self-Pay Program

Estimated Cost Per Visit
Evaluation: $100
Follow up visits: $75

By signing below, I attest that I meet the requirements to participate in the Patient Self Pay program. The contents of this form have been explained to me, and I have voluntarily signed this agreement before receiving the described services. I have been told hat the estimated costs will be. I agree to pay for the services in full or within the guidelines of a formally established payment plan between myself and the Provider.

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