Last update: March 12, 2020
The team at MOCA Healthcare sincerely appreciates the confidence you have shown in selecting us to provide for your rehabilitation needs. The services you have elected to participate in implies a financial responsibility on your part. This responsibility requires you to ensure payment in full of your fees. At this time, MOCA Healthcare does not accept, and will not bill, insurance on your behalf. However, you can submit for insurance reimbursement on your own, should you choose.
You, the patient, are responsible for full payment at the time of services. Should your account balance not be paid in full for whatever reason it will be referred to a collection agency. Any fees incurred in collecting on your unpaid balance will be your responsibility. For you convenience, we accept all major credit cards via our payment services within our app. Payment is expected at the time services are rendered, and will be collected immediately upon the completion of services. Prior to service, MOCA Healthcare reserves the right to place a small hold on your funds to ensure availability of necessary funds for payment.
I have read the above policy regarding my financial responsibility to MOCA Healthcare for providing various therapy services to the above named patient, or me. I certify that the information provided is, to the best of my knowledge, true and accurate. I agree to pay MOCA Healthcare the full and entire amount of all bills incurred by me or the above named patient, if applicable, any amount due after services are rendered.
You agree that in order for us to collect any amount you may owe, we may contact you by any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or emails, using any email address you provide to us. Methods of contact may include using pre-recoded/artificial voice messages and use of automatic dialing devices, as applicable
I am aware of my diagnosis and voluntarily consent to have MOCA Healthcare, through its appropriate personnel, provide evaluation and/or treatment as professional deemed necessary by a MOCA Healthcare Licensed Therapist. I understand the practice of physical therapy is not an exact science, and I acknowledge that no guarantees have been given to me regarding the successful completions or the results of the treatment provided. I understand that the treatment I receive from MOCA Healthcare is limited to Physical Therapy services and that I shall seek treatment from other medical professionals for all other issues I may experience. I understand that I have the right to ask questions at any time during the course of my care.
I further authorize MOCA Healthcare to release to appropriate agencies, any information acquired in the course of my or the above named patient’s examination and treatment necessary to secure payment for services provided.
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