Your First Visit
Welcome to Surge Mobile Physical Therapy! We are so appreciative that you decided to choose us for your care. Below are a few things that will help us create a great and smooth experience with us.
- Please arrive at your Initial Evaluation appointment 15 minutes prior to your actual appointment time (Please note that the Olmito & Port Isabel and Port Isabel locations are closed Monday-Friday from 12-1 PM for lunch. Therefore, if your appointment time is at 1 PM, please arrive on time). This will allow you time to check in and fill out any paperwork required. We respect your time and will see you promptly at your appointment time. Please note, we have a no-show and cancellation fee of $50 if we are not notified more than 24 hours prior to your scheduled appointment.
- Please bring comfortable/gym attire so that we can assess and treat the body part you are coming in for more effectively and efficiently.
- During your evaluation, the Physical Therapist will explain exactly what to expect. If this is your first time, don’t worry, the front office staff and PT will walk you through it step by step.
- At the end of the evaluation, the Physical Therapist will explain to you a specific plan of action to reduce your pain and get you back to full activity. NOTE: Please let me know if there’s anything that will affect your plan of care. If it is determined additional sessions are needed after the Initial Evaluation, we ask that you schedule ALL of your visits with the front desk so please don’t forget your calendar.
- Payments are due (copay or deductible) at the end of each visit. If you have ANY questions about your insurance benefits, please let our front desk know. Nobody likes “financial” surprises.
- INSURANCE: As a COURTESY to all patients, We will verify your Outpatient Physical Therapy Benefits, but YOU are responsible to know your Plan coverage, exclusions, and limitations. This ESTIMATED amount not covered by your insurance is due at the time of treatment and must be paid by cash, credit card, cash app, care credit, or checks.
During ALL insurance eligibility checks, YOUR insurance lets us know that VERIFICATION OF BENEFITS IS NOT A GUARANTEE OF FULL COVERAGE, IT IS AN ESTIMATION ONLY.
This means ALL ESTIMATES ARE SUBJECT TO FINAL APPROVAL BY YOUR INSURANCE PLAN, AND THEREFORE, IS SUBJECT TO CHANGE AFTER THE FINAL EXPLANATION OF BENEFITS HAVE BEEN PAID. This means that the ESTIMATED amount YOUR insurance tells us to charge you MAY CHANGE AFTER YOUR INSURANCE FINISHES FULLY PROCESSING ALL YOUR CLAIMS.
This is why, WE ALWAYS recommend that you save all your EOB (Estimation of Benefits) statements that YOUR insurance sends you directly. We also recommend to always get a name AND a reference number of the insurance representative you spoke with to help with verifying the information the insurance tells you.
Information about Copay, Co-insurance, and Deductibles:
A COPAY is a set amount YOUR insurance tells us your are responsible for in order to receive our Outpatient Physical Therapy services. However, Outpatient Physical Therapy Visits do not ALWAYS fall under a copay.
A CO-INSURANCE is a partial percentage that YOUR insurance tells us your are responsible for paying in order to receive our Outpatient Physical Therapy services. Most of the time, your co-insurance goes towards your yearly DEDUCTIBLE. IF YOUR INSURANCE TELLS US AT THE TIME OF VERIFICATION OF BENEFITS THAT YOU HAVE NOT MET YOUR DEDUCTIBLE, YOU WILL BE FULLY RESPONSIBLE FOR THE VISIT CHARGE AT THE TIME OF SERVICES. Outpatient Physical Therapy Services sometimes fall into a deductible that you have to meet based on your insurance plan.
As a COURTESY, our billing department can help you call your insurance and ask about any specific questions you have, but if YOUR insurance does not fully cover your sessions, then YOUR INSURANCE TELLS US THAT ANY REMAINING BALANCES ARE PATIENT RESPONSIBILITY. YOUR insurance ALWAYS recommends that you can call them directly for any questions.
If there are any CREDITS owed back to you, please let us know right away to VERIFY WITH YOUR INSURANCE, and process your refund accordingly. Refunds are typically processed AFTER YOUR CASE IS DISCHARGED, via checks, and when all information being verified to be correct by our billing department.
Any bounced checks or unpaid balances due will get billed to you directly, and if left unpaid, sent to a third party collections agency.
All of us at Surge Mobile Physical Therapy want to welcome you to our family and we are looking forward to working with you.
Patient Forms
In English
Save time at your first visit! Complete your New Patient Forms online before you come, or print them out. Don’t forget to bring your forms, insurance cards, and photo ID.
IF PRINTING:
To save time, please contact our office first to confirm which packet you need. If you bring the wrong one to your visit, you’ll need to complete the correct packet here.
Be sure to print the right one!
⚠️ Important ⚠️ Please Read Before Filling Out Any Form
To avoid delays in your care, please ONLY complete the form that our office has confirmed for you.
If you are unsure which form to complete, please do not guess. Contact our office and we will tell you exactly which form you need. Filling out the wrong form may delay your appointment.
Car Accident (Not Work-Related)
For injuries caused by a car accident that did NOT happen at work.
Private Insurance (Blue Cross, Aetna, United, etc.)
For patients using private insurance that is not related to a car accident or work injury.
Medicare (65+ or Disability)
For patients covered by Medicare.
Paying Without Insurance
For patients paying out of pocket with no insurance coverage.
Work-Related Injury
For injuries that happened on the job and are being billed to your employer’s insurance.
Other Forms
Optum/United PSF Form
Financial Hardship Disclosure Form
Medical Record Request Form
Payment Plan Agreement Form
YPR Form
En Español
¡Ahorre tiempo en su primera visita! Complete sus Formularios de Nuevo Paciente en línea antes de venir, o imprímalos. No olvide traer los formularios, sus tarjetas de seguro y su identificación con foto.
SI VA A IMPRIMIR:
Para ahorrar tiempo, por favor contacte primero a nuestra oficina para confirmar qué formulario necesita imprimir. Si trae el formulario incorrecto a su cita, tendrá que completar el correcto aquí.
¡Asegúrese de imprimir el formulario correcto!
⚠️ Importante ⚠️ Lea Esto Antes de Completar Cualquier Formulario
Para evitar demoras en su atención, por favor complete ÚNICAMENTE el formulario que nuestra oficina le haya indicado.
Si no está seguro(a) de cuál formulario completar, no adivine. Comuníquese con nuestra oficina y con gusto le indicaremos el formulario correcto. Completar el formulario incorrecto puede retrasar su cita.
Accidente de Auto (No Relacionado al Trabajo)
Para lesiones causadas por un accidente de auto que NO ocurrieron en el trabajo.
Seguro Privado (Blue Cross, Aetna, United, etc.)
Para pacientes que usan seguro privado y cuya lesión no está relacionada con un accidente de auto ni con una lesión laboral.
Medicare (65+ o Incapacidad)
Para pacientes cubiertos por Medicare.
Sin Seguro / Pago en Efectivo
Para pacientes que no cuentan con seguro médico y pagan por su cuenta.
Lesión en el Trabajo (Workers Comp)
Para lesiones ocurridas en el trabajo que serán facturadas al seguro de su empleador.