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**If requesting a courtesy refund of a fee incurred, please summarize the extenuating circumstance that you believe entitles you to a refund.

By checking this box, I confirm that my patient information is true and accurate. I am submitting this form as a patient of Onondaga Physical Therapy asking a financial question related to my Physical Therapy services or insurance coverage only. I certify that I am not soliciting for sales, marketing or pitching a business-related inquiry through this form. Sales, Marketing and other business-related inquiries should be made directly to marketing@onondagapt.com.