FINANCIAL POLICY FOR ASSOCIATES IN FAMILY MEDICINE (updated 1/1/2019)
To our Patients,
We are committed to building a successful physician-patient relationship with you and your family. Your clear understanding of our Patient Financial Policy is important to our professional relationship. Please understand that payment for services is part of that relationship. Please ask if you have questions about our fees, our policies, or your responsibilities.
We are contracted with many insurance companies, including Regence Blue Shield, Premera Blue Cross of WA, Kaiser, United HealthCare, Aetna, Cigna, Uniform Health, Medicare, First Choice, Dept of Labor and Industries and others. It is your responsibility to ensure we are in Network with your insurance and if required, you have selected or been assigned to an Associates in Family Medicine Provider, prior to arriving for your appointment. Due to the number of insurance companies in existence, AFM, may not have access to verify eligibility nor will AFM verify what your insurance benefits cover.
EXPECTATIONS: each insurance plan is a contract between you and your insurance company. The patient is responsible to verify coverage for services. We do not verify which services are covered under your wellness benefits or how often you are eligible to receive them. We will not change the reason for a visit if your insurance applies it to your deductible. As a general rule, any surgical (invasive) procedure such as ear cleaning, sutures, lesion removals, wart removal, therapeutic injections; will be applied to your deductible. Corns and callus paring and toenail trimming is generally considered not medically necessary unless you have underlying medical conditions.
PAYMENT: is expected at the time of your visit. We accept cash, check, or credit card. Payment will include any unmet deductible, co-insurance, co-payment amount, or non-covered charges from your insurance company. If you do not carry insurance or do not provide complete insurance information (current insurance card) and government issued identification with photo id, payment will be expected at the time of service. Due to an increase in identity theft, fraud and DEA scrutiny, your identity must be verified. Your balance after insurance processes is expected to be paid in full within 30 days of receiving your initial statement. We have an arrangement with Care Credit for patients who are unable to pay their balance in full within 30 days. You may apply online or ask for an application in the office.
SELF PAY PATIENTS: UNINSURED PATIENTS ARE REQUIRED TO MAKE A DEPOSIT of $150 cash or credit/debit (no checks), prior to their appointment. THIS IS A DEPOSIT ONLY, not a guarantee of the cost of the visit. The remainder of the visit is due after treatment completion. A 10% cash discount will be honored for visits paid in full on the date of service when there is no outstanding balance on the account. This discount applies to E&M services only (visits). Laboratory tests, surgical procedures, supplies or medication/immunizations, form completion are never discounted. By signing below I state I am not eligible for Medicaid/ Veterans Administration/ Champus/Champva/Tricare and will not ask Associates in Family Medicine to bill them. All private pay patients are required to pay for their visits in full on the date of service. We accept Visa, MasterCard, Discover, debit cards, personal checks (subject to verification of funds available) and cash
INSURANCE EXCLUSIONS: We are not billing Veterans Administration, Champus/Champva or Tricare and are currently not accepting Medicaid (Molina) covered patients. Out of State HMO plans may not be covered. Patients will be personally responsible for balances if they fail to disclose coverage by these plans and Associates in Family Medicine will not be obligated to continue the patient relationship.
MOTOR VEHICLE OR PERSONAL INJURY CLAIM: Effective January 1, 2019 we no longer bill for these claims. We will provide you with everything you need to bill your insurance yourself. If your Personal Injury Protection (PIP) coverage is exhausted, you may arrange with your regular health care plan to cover the visits.
ALL COPAYS MUST BE PAID IN FULL WHEN YOU CHECK IN FOR YOUR APPOINTMENT. Patients who do not make their payment on the date of service will be billed an additional service fee of $10.00. This fee is the sole responsibility of the patient and will not be covered by any insurance company.
IDD Therapy/Accuspina: is never billed to insurance. Pre-payment for these services is required. A pre-payment discount is offered for 20 treatments.
FAILURE TO SHOW OR CANCEL AN APPOINTMENT WILL BE BILLED A $40.00 FEE, (cancellations without 24 hours notice given to the clinic). This fee will extend to appointments for IDD Therapy (back machine) and Botox/cosmetic appointments.
NSF fee: All NSF checks will be billed a $35.00 NSF fee and are subject to legal action if not cleared immediately.
FORM OR LETTER COMPLETION: for disability paperwork or any other paperwork not paid for by the requestor will be billed to the patient. These forms are not billable to your insurance company.
CERTIFIED LETTER FEE: If a certified letter is sent to you for pre-collection reasons or termination of services notification you will be billed the current rate of a certified return receipt fee according to USPS.
MINOR CHILDREN: We will not become involved in any custody issues of minor children. The parent who presents to the clinic with the minor child will be personally responsible for any balance.
We thank you for your cooperation and understanding.
The Physicians and Management of Associates in Family Medicine.
Effective 4/1/2009 Amended 1/1/2019