As a courtesy we will bill your primary insurance carrier if you provide ALL necessary
information (such as insurance cards with their CORRECT billing address and REFERRALS).
Co-pays are collected for each visit at the time of service.

Statement of Financial Responsibility

I understand my insurance carrier may not approve or reimburse my medical services in full due
to usual and customary rates, benefit exclusions, coverage limits, lack of authorization, or
medical necessity. I understand I am responsible for fees not paid in full, co-payments, and
policy deductibles and co-insurance.


HIPPA Required Field.
HIPPA Required Field.
HIPPA Required Field.

For billing purposes we require this form to be fully completed. We reserve the right to reschedule
any appointments due to incomplete forms or tardiness. Thank you for your cooperation.

Allcare Therapy Services is an in-network provider with most major health insurance plans. We work directly with your insurance company.