Welcome! Thank you for choosing ACTIV Physical Therapy!

What to do for your first visit

 

  1. Complete the New Patient Registration
  2. Complete the appropriate Functional Questionnaire
  3. Email the completed forms back to us at info@ACTIVpt.com (or bring them with you to your evaluation)
  4. Email a photo of the front and back of your insurance card to info@ACTIVpt.com (or bring it with you to your evaluation)
  5. Call your insurance company to verify your physical therapy benefits
  6. Review our Financial Responsibility Agreement 

 

On the day of your appointment

  1. Wear comfortable clothing that allows you to move freely
  2. Bring any prescription from your doctor, imaging reports, or other information that may be helpful

 

New Patient Registration
New Patient Registration.pdf
Adobe Acrobat document [72.4 KB]

Functional Questionnaires

Please complete the apprortiate questionnaire that applies to your injury or where you are having pain. If there is more than one that applies to you, please complete both. 

Back Index
For Lower Back and Mid Back
Back Index.pdf
Adobe Acrobat document [76.4 KB]
Quick DASH
For Shoulder, Elbow, Wrist, Hand, Arm
Quick Dash.pdf
Adobe Acrobat document [76.7 KB]
LEFS (Lower Extremity Functional Score)
For Foot, Ankle, Knee, Hip, Legs
LEFS.pdf
Adobe Acrobat document [79.2 KB]
Neck Index
For Neck, Upper Back, Shoulder blade region
Neck Index.pdf
Adobe Acrobat document [76.4 KB]

Policies

Financial Responsibility
Financial Responsibility.pdf
Adobe Acrobat document [67.6 KB]
Notice of Protected Health Information Practices
ACTIV-HIPPA-PHI-POLICY.pdf
Adobe Acrobat document [40.4 KB]

Insurance Overview

ACTIV Physical Therapy is In Network with Medical Mutual, Anthem and MultiPlan. 

We also accept Medicare. 

 

If you have United Healthcare, Aetna, or Cigna, please check your insurance card to see if your plan is participating in MultiPlan. There will be a logo on your card. MultiPlan functions between us, the provider, and your insurance company. Since we are part of the MultiPlan Network, this is to your benefit as a patient, if your plan is participating. Essentially, MultiPlan discounts patient responsibility. The discount is not quite the price of In Network, but definitely helps with the Out of Network cost.   

 

If you are out of network and your plan is not participating in MultiPlan, we offer a facility discount of 35% to help offset additional patient responsibility. 

 

Please contact our office directly for additional questions regarding insurance, as each plan varies. 

Financial Responsibility

Thank you for choosing ACTIV Physical Therapy! We are committed to your entire experience here being successful. Our goal is to be proactive regarding any financial responsibility and to establish a mutual understanding of each patient’s cost.

 

As a courtesy, ACTIV Physical Therapy will contact your insurance carrier to verify your physical therapy benefits prior to your first appointment. To do so, we need complete and accurate insurance information about your policy including ID number, group number, policyholder name and date of birth, along with patient name and date of birth. While we may obtain an estimate of your coverage, this does not guarantee payment by your insurance company. We encourage you to review your insurance coverage and accurately verify and understand your policy’s deductible, co-payment, coinsurance, visit limitation, effective annual calendar renewal date, and any pre-authorization requirements.

 

Ultimately you are responsible for the full payment of your bill, and any services not covered by your insurer.

 

You are responsible for notifying us of any insurance changes during your course of care. Failure to do so may result in denial of coverage by your insurance company. ACTIV Physical Therapy will submit claims to your insurance company. If needed, we will resubmit to ensure payment for covered services. In the event that repeated submission does not satisfy your bill for services rendered, you will be responsible for the full payment.

 

IN-NETWORK

You are responsible for meeting the in-network deductible before your insurance will begin to reimburse for the services rendered. You are responsible for co-payments and/or coinsurance as specified in your “Schedule of Benefits.” ACTIV Physical Therapy has agreed to accept the maximum allowable amount as payment in full. If the allowed amount is applied to your deductible, that is your total responsibility. Copayments are due at time of service and payments toward your deductible are required each visit.

 

OUT-OF-NETWORK

You are responsible for meeting the out-of-network deductible before your insurance company will begin to reimburse for the services rendered. If there are no payments from your insurance company, patient responsibility is the entire billed amount. As a facility, to help offset the out-of-network cost, we discount patient responsibility by 35%. This holds true even when insurance makes payments, as patient responsibility for out-of-network includes the remainder of billed charges after an insurance payment.

Payment of at least $50 is required each visit which will be applied to your account balance.

 

MULTIPLAN

MultiPlan is a company that is separate from insurance, but processes claims. If your insurance plan participates in MultiPlan, there will be a logo on the back of your insurance card. Essentially, MultiPlan is somewhere between In Network and Out of Network. Depending on the plan and insurance company, the discount through MultiPlan varies. In this scenario, MultiPlan will replace the 35% Discount mentioned above.

 

SELF PAY

If you have a very large deductible and are out-of-network, we offer a self-pay option. There is a 40% discount on the total billed charges and we do not submit to insurance.

 

WORKER’S COMPENSATION

We are a BWC Certified clinic. We must have authorization prior to any treatment. This is called a C9 and needs to be signed by your physician and approved by worker’s compensation. We also need a copy of your personal insurance, in the event that claims are denied, we will alternately bill your personal insurance. If claims are denied by your personal insurance, you will be responsible for full payment of your bill.

 

MEDICARE

We accept Medicare and other Medicare alternatives. We need a physician’s referral or prescription for physical therapy on file before treatment. If you do not have one, but have spoken with your physician regarding physical therapy, please contact your doctor to have a script written.

 

SECONDARY INSURANCE

If you have secondary insurance you must present it at your initial visit. The same policies and responsibilities apply as primary insurance.

 

MINORS

A parent or legal guardian must accompany the minor at the initial visit. If parents are separated and both legally responsible for the child, complete information for both parents is required.

 

STATEMENTS

Statements are mailed monthly. We expect timely payments on your account. Should you have a dispute, please contact us.

 

COLLECTIONS

We try to avoid sending any account to a collection agency. Our goal is to be proactive to minimize outstanding balance issues by establishing a payment plan ahead of time. You will be contacted by phone and mail with payment plan information. We will send your account to collections if your balance remains unpaid.

 

UNCOVERED PRODUCTS AND SERVICES

Throughout the course of your treatment you may need a brace or other therapeutic supplies recommended by your physician or physical therapist. ACTIV Physical Therapy will not submit claims for braces or supplies to your insurance company. You are responsible for payment of these products when you take them with you. You may submit the receipt for these purchases on your own to you health savings account.

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