Mendelson Kornblum Physical Therapy
Attendance Policy:
Thank you for selecting Mendelson Kornblum Physical Therapy.  We care about your progress in therapy.  Consistent attendance is needed for effective therapeutic results:  It is the policy of this facility to discontinue therapy if you cancel 3 appointments or fail to show for 2 appointments.  Insurance carriers may view inconsistent attendance as a reason to reject a claim.  Please make every effort to keep your therapy appointment.  If you need to cancel, please call (586) 582-0340 and we will attempt to reschedule your appointment.

Punctuality is also very important.  Please arrive on time for your scheduled appointment time.

Insurance:
Please be aware that your insurance carrier may not cover the therapies that your physician has ordered.  It is recommended that you call your insurance company to verify your coverage for therapy.  It is your responsibility to know your individual insurance coverage regarding deductibles and/or co-payments.  By being responsible and knowing what your insurance benefits cover, should help avoid unexpected costs to you.  A statement of benefits is not a guarantee of payment:

Emergency Contact:
If during the course of therapy treatments the therapist determines that emergency care is required, it is understood that 911 will be called and you will be transported to a nearby hospital by ambulance.  We will also contact a family member or friend of your choice

Available family member or friend's name:_______________________________________________

Number: _______________________________________________________________________

Patient's Signature: _______________________________________________________________

Witness Signature: _______________________________________________________________