1.) You are responsible for providing us with correct insurance information, including name of employer, group number, subscriber’s social security number, and a toll free telephone number to contact the insurance carrier.

If you desire additional information about your insurance coverage it is

YOUR RESPONSIBILITY to obtain whatever information you want directly from your insurance carrier or your human resources contact person. We recommend using the toll free customer service number listed on your insurance card.

2.) Apex Therapy Clinic will prepare and file your insurance claims directly to your primary and secondary insurance carriers on your behalf. It is the

PATIENT’S RESPONSIBILITY to ensure insurance payments are processed and pain promptly. In the case of default payment, I promise to pay any legal interest on the balance due, collection costs (35% of balance due) and reasonable attorney fees incurred to satisfy this account.

3.) Apex Therapy Clinic will keep you informed of any outstanding balance via statements. We will allow 60 days for your insurance carrier to reimburse us. If your insurance carrier fails to issue reimbursement within this timeframe, the outstanding balance will be your full responsibility for which you will receive a statement. Failure to pay this balance will result in finance charges being applied to all balances over 60 days from date of service.

4.) We require that you pay your estimated portion of the total fee at the time of service. We accept cash, checks, or major credit cards.

5.) Your time as well as Dr. Bauer’s time is very valuable. If the need arises that you have to reschedule an appointment, please provide us with a minimum of 24 hours notice so that we have time to contact other patients that are waiting for that time-frame. Failure to notify us in a timely manner or missed appointments will be assessed a $50.00 fee.

Signing this document acknowledges that I have read the above information.


Patient Name Printed


Patient / Guardian Signature




Relationship to Patient