406A-Black Hills Lane SW
Olympia, WA 98502
(360) 754-1727 FAX (360) 754-1783
INSURANCE INFORMATION
Primary Insurance:
Subscriber ID#
Group#
Effective Date:
Relationship:
Subscriber Name:
Date of Birth:
Secondary Insurance:
Subscriber ID#
Group#
Effective Date:
Relationship:
Subscriber Name:
Date of Birth:
FINANCIAL AGREEMENT, EXTENSION OF CREDIT AND AUTHORIZATION FOR TREATMENT
I authorize treatment of the person named above. I understand that services provided may not be covered by my insurance carrier. I agree to be personally and financially responsible for payment in full of all fees and charges for such treatment, regardless of my insurance coverage and referral procedures. I agree to pay all charges for myself and members of my family shown by statement, promptly upon presentation thereof, unless credit arrangements are agreed upon in writing.
In accordance with the Federal Truth-in-Lending Act which requires us to give our patients information in connection with extension of credit, please be advised of the following policies which apply in this clinic. The responsible party agrees:
1. To pay the doctor at the time treatment or service is received or by previous arrangements.
2. That if payments are extended beyond 60 days from the date of patient responsibility to pay 1% per month on the unpaid balance (annual rate of 12%) with a minimum charge of $1 per month.
3. Missed or cancelled procedures within 72 hours of the scheduled appointment time will incur the following fee’s
$200.00 charge for a procedure
$75.00 charge for imaging
$50.00 charge for office visit *within 48 hours
It is agreed that payments will not be delayed or withheld because of any insurance coverage or the pendency of claims thereon, and all proceeds of insurance are assigned to this office where applicable, but without their assuming responsibility for the collection thereof. A copy of this assignment is as valid as the original.
Electronically signed by:
Date:
OMNIBUS BUDGET RECONCILIATION ACT OF 1990 (OBRA '90') ADVANCE DIRECTIVES
Do you have a living will?
Do you have a durable power of attorney for health care?
If not, do you wish additional information?
The existence or execution of a living will, durable power of attorney for health care, or other written advance directive is not a condition of receiving health care services and may not otherwise be used to discriminate an individual.
Electronically signed by:
Date:
PAYMENTS OF BENEFITS – AUTHORIZATION
I authorize payment of medical benefits to the Olympia Multi-specialty Clinic for any services furnished me. I also authorize the release medical or other information necessary to process claims for these services provided.
Electronically signed by:
Date:
AUTOMATED TELEPHONE SYSTEM – AUTHORIZATION
I authorize Olympia Multi-specialty Clinic to use an automated telephone system and to use my first name, the name of the treating physician, and the time and place of my scheduled appointment(s), for the limited purpose of notifying me of a pending appointment(s). I also authorize Olympia Multi-specialty Clinic to disclose to third parties who may answer my phone, limited protected health information regarding my pending appointment(s).
Electronically signed by:
Date:
TELEMEDICINE – AUTHORIZATION
I authorize Olympia Multi-specialty Clinic to use a Telemedicine systems to conduct my visit if it is scheduled as a remote or telemedicine appointment. I also authorize Olympia Multi-specialty Clinic to use e-mail for scheduling these appointments which may contain, limited protected health information regarding my pending appointment(s).
Electronically signed by:
Date:
CONFIDENTIAL MESSAGES ON ANSWERING MACHINE OR VOICE MAIL - AUTHORIZATION
I authorize Olympia Multi-specialty Clinic to disclose protected health information on my answering machine or my voice mail.
Electronically signed by:
Date:
ELECTRONIC MEDICATION HISTORY - AUTHORIZATION
I authorize Olympia Multi-specialty Clinic to obtain my medication history on my behalf.
Electronically signed by:
Date: