Ocean Natural Health Soniya Gandhi N.D., B.H.M.S.

The Sage center 12555 SW 1st St. Call-971-217-6556

Beaverton OR 97005

Financial Policy

Welcome to Ocean Natural Health. Dr. Soniya Gandhi is committed to providing the best care possible and appreciates your trust. Please take your time to review thefollowing information and sign and date below.

  • The clinic will charge a fair price for all services and products rendered as a partof delivered healthcare.
  • All fees for products-supplements and services are due at the time of service. Any charges incurred as a result of delivered healthcare are the soleresponsibility of the patient / client.
  • We are happy to bill for you provided we have all the necessary information including insurance company, billing address, patient's legal name and birth date, guardian's legal name, birth date and address if the patient is a minor, patient's insurance identification number, group number (if applicable). To ensure coverage, this information is best given prior to your appointment so that we may verify coverage. A copy of the insurance card is required. If mailing address or insurance coverage changes, please notify our office as soon as possible.
  • INSURANCE

The following information is required for insurance billing. Please fill what is applicable to you.

Insurance? Yes  No

Primary Insurance Name: ______

Phone #: ______

Policy/ID Number: ______

Group Number: ______

Insured's Name:______

Secondary Insurance:______

Insured's mailing address: ______

Employer Name: ______

Primary Insurance holder’s Name ______

Primary Insurance holder’s Date of birth ______

Primary Insurance Holder’s Address______

______

Primary Insurance holder’s telephone no.______

Primary Insurance holder’s Employer’s Name ______

Insurance Program Name______

Primary Insurance holder’s Policy Number ______

  • We allow 60 days for insurance processing. If your insurance company has not responded within that time period a payment is expected from you. An insurance policy is a contract between you and your insurance company. You are responsible for the fees due for the clinical services regardless of the action of the insurance company. A regular monthly payment plan can be arranged if you are unable to pay the entire balance at once. Your cooperation is requested so that we may continue to provide excellent healthcare services for this community. Final responsibility for payment of your visit and your account is yours.
  • For our services, we accept payments in the form of cash or check at this time. Please make the checks payable to Ocean Natural Health.
  • Returned checks: Our bank charges us whenever a patient presents a check that does not have sufficient funds available. Therefore, we must charge you a $35.00 handling fee. All future visits will need to be paid with either cash or a credit card.
  • Patients will be responsible for charges incurred for any appointment(s) cancelledwithout 24-hour prior notice to the clinic.
  • MEDICAL RELEASE: I hereby authorize the release of medical information necessary to process my insurance claim and any future insurance claims, without obtaining my signature on each claim. This may include intake forms, chart notes, reports, correspondences, billing statements and any other information to my attorneys, health care providers and insurance case managers.
  • AUTHORIZATION OF PAYMENT: I authorize payment of medical benefits directly to Ocean Natural Health, LLC.

I am responsible for all charges of all services provided. In the event that my insurance company denies benefits or makes a partial payment, I am responsible for any balance due.By signing below you signify that you have completely read and agree with theabove terms and conditions.

Printed Name: ______

Signature: ______Date: ______