Assignment of Benefits

(To be signed & dated if using out-of-network insurance plan)

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 Clinton Lee Physical Therapy LLC/PhysioStrength for all therapy services rendered. I also agree to remit any monies sent to me from my insurance company for services rendered to Clinton Lee Physical Therapy LLC/PhysioStrength. I agree to pay for all services rendered UP to $200.00 (the out-of-pocket cost for a one hour 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. (Please enter full name below)

Name *
Today's Date *
Today's Date