Download Medicare intake form - Bounce Back Physical Therapy

Medicare
Medicare will pay 80% of the allowed contracted charges for physical therapy. The 20%
difference is either billed directly to your supplemental insurance for re-imbursement or
will be billed directly to you as your patient responsibility.
For 2014, Medicare allows $1,920 for physical and speech therapy combined.
It is your responsibility to verify how much of your 2014 benefit remains before you start
physical therapy with us here at Bounce Back. This information can be obtained by
contacting Medicare directly. The phone number is listed on the back of your Medicare
insurance card.
Please sign to acknowledge that you understand your Medicare benefits as described
above.
Signure_____________________________________________Date________________