2025 Financial Responsibility Agreement

Thank you for choosing Evens Physical Therapy, LLC for your physical therapy and performance training. We are honored by your choice and committed to providing you the highest quality physical therapy and training. Please read and sign this agreement to acknowledge that you understand our patient financial policies, which are as follows: 1) The patient (you) are ultimately responsible for all payment for treatments and training. 2) The patient is responsible for all charges associated with insurance co-pays and non-covered charges. 3) The patient is responsible for any costs associated with collections of unpaid patient balances. 4) patient statements are mailed on a monthly basis. The patient is responsible for making the payment within 30 days of the date that appears on the patient statement. 5) The patient is aware and understands that failure to make payment for treatment or training will result in collection actions being taken to collect the debt. 6) All cancellations must be made with >24 hour notice or a 50$ late cancellation fee will be applied.

Patient Authorization: I hereby authorize assignment of financial benefits from healthcare and insurance entities directly to Evens Physical Therapy for services provided as allowed under standard contracts. I understand and agree that I am financially responsible for all charges not covered. I have read, understand and agree to the terms of this Financial Responsibility Agreement. 

Cost of Treatment: 

• Cash Pay (insurance not involved) 150$ initial visit, 125$ followup visits 

• Cash Pay collected when insurance processed towards deductible 150$ initial visit, 125$ followup visits

Waiver of Authorization: I choose to pay at the time of service and to be fully responsible for all charges and to submit claims to my insurance company at my own discretion.