Insurance Coverage
You are financially responsible for Mast Clinic charges not covered by your child’s health insurance. It is important to understand whether physical therapy services are covered and what you are responsible for paying out of pocket. If Mast Clinic's services are not covered, we accept private pay and Briana can work with you on a payment plan.

We recommend contacting your insurance company before your first appointment to confirm coverage for physical therapy services.  

You want to tell them:  “ My child has been referred for physical therapy evaluation and treatment”

While in contact with your insurance company, please fill out this form.
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Child’s name:
Date of birth:
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Insurance company:
Certificate #:
Please record the following information :
Who you talked to at the insurance company:
Date
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DD
/
YYYY
Time
Time
:
Are physical therapy services at Mast Clinic covered by child’s plan?
Clear selection
Co-pay (to be paid at time of service) or percentage  you will be responsible for:
Does your child's plan require a deductible for the calendar year before coverage begins?  If yes, what is the amount and has the deductible been met for this year?
Are there a limited number of PT sessions covered per year? If yes, how many sessions covered?
Is there a limited dollar amount covered per year? If yes, what is the amount?
Is a referral and/or prior authorization required?
Clear selection
If referral is required, call your child’s primary care physician’s office with the above information. Ask that your child’s doctor make a referral for physical therapy evaluation and treatment.
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