Financial treatment agreement - Functional Performance Center 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by reviewing the initial section regarding billing. Here, you will acknowledge that The Functional Performance Center will bill your insurance and that any funds received must be paid directly to them. Initial this section to confirm your understanding.
3. Next, address your financial responsibility. Read through the terms regarding missed appointments and initial to agree that a $25 fee applies if you do not cancel at least 24 hours in advance.
4. Proceed to the Authorization for Treatment section. Carefully read the risks associated with physical therapy and initial to indicate your consent to participate fully in the treatment plan.
5. Finally, review the payment policies, including co-pays and potential collection fees. Ensure you understand these terms before signing at the bottom of the form.

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