Physical Therapy Patient Paperwork

If you are coming in to get treated for a specific condition by a licensed physical therapist or licensed physical therapy assistant, then you'll need to fill out these forms.

Physical Therapy TREATMENT Paperwork & Instructions

Wellness & Fitness Paperwork (For Private Sessions)

If you are coming to see us for wellness or fitness, regardless of whether it is by a physical therapist, physical therapy assistant, or Pilates/Movement teacher, then you'll need to click below to fill out these forms.

Wellness/Fitness Paperwork & Instructions


Time is your most valuable commodity. The quality and expertise of the ProBalance team enables you to reach your goals in the most efficient way possible, leaving time to enjoy the things that mean the most to you. We have a variety of pricing options to serve a range of needs and budgets for both rehabilitation and wellness, and many services are eligible for submission to health insurance and/or FlexSpend plans.

Rates Effective:  January 5, 2020
Highly Skilled PT- one-on one w/a licensed physical therapist or licensed PTA for entire session
Receipts for these sessions may be submitted to insurance or flex spend (NOT Medicare–read below) $200 Initial PT Evaluation & Treatment (50 min) $150 PT Treatment (45-50 min) (PT insurance rates billed at $50 per 15 min unit)
PRIVATE PILATES for Fitness/Wellness - 50 min session
Initial Functional Movement/Fitness Session with Assessment $200 w/Physical Therapist $100 w/Fitness Pilates Instructor  
Single Private Pilates Session-50min $150 w/Physical Therapist $90 w/Fitness Pilates Teacher  
3-Pack Private Pilates Session-50min $420 w/Physical Therapist $255 w/Fitness Pilates Teacher  
6-Pack Private Pilates 50min (expires in 12 mos) $750 w/Physical Therapist $480 w/Fitness Pilates Teacher  
12-Pack Private Pilates 50 min (expires in 12 mos) $1297 w/Physical Therapist $900 w/Fitness Pilates Teacher  
PILATES DUETS/SEMI-PRIVATE GROUP per person - 50 min session
Single Pilates Duet (55min) $75 w/Physical Therapist $60 w/Fitness Pilates Teacher pp  
Semi-Private Group - 3 or more people  -------------- $45 w/Fitness Pilates Teacher pp  
Extended 85 min Specialized PT/Pilates by a Physical Therapist (Sport/golf/dance/runner)
These rates are not billable to insurance.We may be available to teach at your location for an additional fee for individuals, corporate events, retreats, and more.  Please use the contact form for details. $295
Extended  PT/ Sports Pilates Evaluation (85min)
  $250 Extended PT/Sports Pilates session  ( 85 min)
Pilates & Fitness/Wellness Classes
Pilates eXpress Class (25 min) $25 Single Class
(preregister online)
Pkg of 6 (6 month expiration)
Pkg of 12 (6 month expiration)
Pilates Apparatus/Reformer Classes (50 min) $40 Single Class
(preregister online)
Pkg of 6 (6 month expiration)
Pkg of 12 (6 month expiration)
**Special Intro Price only available 1x by current, former or new clients to ProBalance.
Other Offerings
Apprentice Private Pilates Session (with a Level 1 or Level 2 Apprentice)  50 min Private Session with Apprentice Pilates Teacher  $30-$50/session depending on pkg & level
ONLINE Interactive & On-Demand Classes  $39/mo subscription
**Packages with classes of same per session price are interchangeable between class types and instructors.

*Physical Therapy (PT) Services: While we are an out of network provider, most PPO’s will pay a portion of the physical therapy charges at ProBalance with a physician’s prescription. To ensure our high standard of care, payment is expected at the time of service and a superbill will be issued at the patient’s request with the PT reimbursement codes needed for the patient to submit their own claim.   If you are submitting your superbills to your insurance, please do so after the first or second visit so there are no surprises.  Insurances vary with regards to out of network benefits, deductibles, allowed codes, etc.  

Physical Therapy pricing that will be submitted to insurance will vary based on the services provided as the amounts are billed per procedural unit in 15 min increments. We typically use treatment codes 97110 Therapeutic Exercise and 97140 Manual Therapy.  Sessions that are part of discounted wellness or "cash pay" packages are not eligible for submission to insurance. 

Important information for Medicare Beneficiaries: Please note that we are NOT enrolled as a Medicare provider. If you have Medicare, you will need to use your Medicare benefits first with a Medicare approved PT outside of ProBalance (we would be happy to give you referrals). Our physical therapists cannot accept payment for services for treatment of a specific diagnosis if you have existing Medicare benefits. However, Medicare eligible clients can be seen at ProBalance for our maintenance, preventative, general fitness, and wellness services which are not Medicare eligible interventions. We will have you sign a form indicating that we are performing wellness services only. These charges for wellness will not be billable to Medicare or any other insurance for reimbursement.

If you are seeing us for PT/Pilates for wellness, we can identify movement dysfunctions and structural issues that may be keeping you from achieving optimal alignment, posture, performance, and movement efficiency and utilize our “PT toolbox” to address those findings…the bonus is typically that you look and feel better!

Due to the specialized nature of our business model, we do not accept Worker’s Compensation or liens.

FREE Resources

Understanding WHY you are doing something helps you become an integral part of your own healing.   Click below for some of our free resources listed inside our Online "Be Well-Stay Well™" portal, including simple exercises, mini-workouts, mythbusting videos, a posture & body mechanics checklist, and more.

Click here for access to our FREE video library