North Sound Center for Integrative Medicine, PS

125 N 18th St., Suite B

Mount Vernon, WA 98273

FINANCIAL POLICY

At North Sound Center for Integrative Medicine we feel it is very important that our patients have a clear understanding of our expectations regarding your billing and payment. Our insurance and credit policy is designed to help keep our costs down so that we can continue to provide our patients with quality care at reasonable rates. Please read and sign the following Financial Policy prior to your treatment. Should you have any questions, feel free to ask. You, the patient, are responsible for any and all charges incurred in our office, even if you feel that your charges will be covered by an insurance company, an ex-spouse, attorney, or any other third party.

CANCELLATIONS/NO SHOWS: If you are unable to make your scheduled appointment, please give our office 24 hours notice so that we may give that time to another patient. Showing up for your scheduled appointment on time is very important! Patients that cancel or reschedule on the day of the scheduled appointment will be charged $25.00. For “No Show” appointments, you will be charged $50.00. That charge is the patient’s responsibility as Insurance Companies DO NOT pay for missed appointments.

INSURANCE BILLING: If you are covered by any of the following insurance companies, which we are contracted with, we will be happy to submit your charges once you have provided us with your insurance card: (Medicare, Dept of Labor & Industries, etc.).

Since the insurance policy is a contract between you and your insurance company, we expect you to follow-up with the insurance if timely payment is not made to our office. Should your insurance company ever pay for charges that have already been paid by you, we will promptly issue a refund check to you.

For patients who are not insured through the above, we will be happy to courtesy bill your insurance company if you can provide us with a copy of your insurance card and it has the needed billing information. We will bill ONE TIME ONLY. It will be your responsibility to follow up with your insurance company should they deny or delay payment. Payment in full, regardless of insurance, is expected within 45 days of service. Our office does not bill for any third party liability. Payments for these services are to be paid in full at the time of service. A $15.00 surcharge will be made for co-pays not paid at the time of service.

STATEMENTS: All monthly statements are due and payable in full unless prior arrangements have been made with our billing department. After 30 days (second statement), a finance charge of 1% will be assessed each month. Our office offers payment methods of cash, check or Visa/MasterCard. Any deductible, co-pay or co-insurance is due and expected at the time of service.

If you pay for your services by check and it is returned for non-sufficient funds, we charge an additional $25.00 fee to your account. If that happens, you will be asked to remit the amount of the check plus the service charge in cash within 10 days. If your account has not been cleared by then we will refer it for collection action.

COLLECTION: Failure to make payments or contact our billing department within 60 days will be considered as intent to not pay and we will begin the collection process on your account. If the account remains unpaid and no satisfactory arrangements have been made, your account will be assigned to SB&C Ltd. If your account is referred to the collection agency, you will need to seek care from another physician outside of our clinic. If for some reason your account is referred for legal action, you as the patient are responsible for all court fees, attorney fees, and any and all fees involved.

I HAVE READ AND FULLY UNDERSTAND NORTH SOUND CENTER FOR INTEGRATIVE MEDICINE’S FINANCIAL POLICY.

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Signature of Responsible PartyDate

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Please Print Full Name A copy of this agreement is as valid as the original.