Financial Statement and Billing Disclosures

As a patient of Ozark Rehab and Therapy (ORT), your insurance coverage is verified to determine available benefits.  Even though this information is reliable, it is not guaranteed. You are responsible for knowing the benefits, limitations, and/or restrictions that your policy may stipulate.

We base our information regarding your insurance coverage on what we are given by your insurance company when we verify your coverage.  We then convey this information to you as a courtesy when we file insurance claims on your behalf. The exact determination of benefits occurs at the time your insurance company pays the claim.  Every effort will be made to notify you should a difference occur between what was expected and what was actually paid. You do however, receive notification directly from your insurance carrier what they paid to us, and it is reflected on your monthly statement.

We must emphasize that as medical providers, our relationship is with you.  While the filing of insurance claims is a service that we extend to our patients, it is your responsibility to see that your charges are paid in full.  Any known deductions including deductibles, co-pays, co-insurance, or non-covered services/supplies are due at the time of service. Any amounts rejected for any reason by your insurance company are due at the time of their rejection.  

Ozark Rehab and Therapy are participating with most major insurance networks.  For specific information please speak with our Insurance Verification Specialist.  Financial assistant is available upon request. Please speak with our Financial Counselor for more details.

BILLING DISCLOSURES TO INDIVIDUALS INVOLVED IN PATIENT’S CARE

I authorize Ozark Rehab and Therapy to disclose billing information that is directly related to my current treatment to the individual(s) listed below.


Patient Name *
Patient Name
Date of Birth
Date of Birth
BILLING DISCLOSURES TO INDIVIDUALS INVOLVED IN PATIENT’S CARE
I authorize Ozark Rehab and Therapy to disclose billing information that is directly related to my current treatment to the individual(s) listed below.
I do not wish to have my health information disclosed to individuals involved in my care.
Date *
Date
Date *
Date