Policy Form

Click here for a printable Policy form. If printing the Policy form, please bring it with you to your first appointment or fax it to us at (802) 264-8519.

Referrals: If your insurance company requires a referral, this must be present at the start of care.

Co-pays: Due on the day of service.
Insurance: You are strongly encouranged to contact your insurance company to verify benefits and requirements for physical therapy services and if you have a deductible, co-pay, or co-insurance for which you are responsible.

Procedure: I will collect any co-pays due on the date of service, as required by your insurance company. I will then bill your insurance company for the date of service. After I receive payment from the insurance company, I will bill you if needed for any additional charges you may owe due to an outstanding deductible, co-insurance, or if the company denies the visit. I always call your insurance company on the first date of service to verify your benefits and will work with you to minimize additional charges.

Consent: I consent to be treated for the injury/illness for which I have consulted Kathleen Doehla, M.S. P.T. , within the physical therapist scope of practice.

Agreement: I agree that if my insurance company does not cover these services, because of outstanding copayments, co-insurance, or deductibles, or because of denial, that I am responsible for timely and full payments for services.

Assignment: I authorize Kathleen Doehla, M.S. P.T. on behalf of Points North Physical Therapy to bill my insurance company and receive payment directy from the company for services provided.