I understand that my insurance company will be sent an itemized bill for each session in accordance to reasonable and customary charges. I agree to assign benefits directly to Dr. Dmitry Choklin, PT, DPT for all therapy services rendered. I also agree to remit any monies sent to me from my insurance company for services rendered directly to Dr. Choklin. I agree to pay for all services rendered UP to $350.00 (the out-of-pocket cost for an initial evaluation or follow-up treatment) should my insurance company deny payment for services rendered and will be responsible for any deductible or co-insurance due as per the terms of my insurance plan.
Cancellation policy: If I cancel my session within less than 24 hours notice. Insurance cannot be billed for a missed session. The first cancellation will incur a $75 fee, all subsequent cancellations will cost $150. I want you here more than your money, so please don’t cancel! For special cases, the charge may be waived if the session is made up later in the week. But again, please try not to cancel. We do not charge you the actual cost for that appointment, but rather a smaller fee. We do not make a profit with this charge; it’s only to act as a deterrent from making last minute changes. Advance notice allows someone else (who needs it) the opportunity to reserve it in place of you.
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917-328-8098