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Thank you for choosing Rebel Med Northwest and its providers for your medical treatment and care. We are committed to providing you with quality and affordable health care. Because some of our patients have had questions regarding patient and insurance responsibility for services rendered, we developed this payment policy. Please read it, ask us any questions you may have, and sign in the space provided. A copy will be provided to you upon request.

  1. Insurance. We participate in most insurance plans, if you are not insured by a plan we do business with, payment in full is expected at each visit. If you are insured by a plan we do business with but don’t have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage. Some insurance companies may require pre-authorization before receiving certain procedures, if you know this is the case, please let us know, so we can help facilitate any processing of forms to ensure timely care is achieved.
  2. Co-payments, Co-insurance, and deductibles. All co-payments, co-insurance, and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment at each visit.
  3. Non-covered services. Please be aware that some and perhaps all of the services you receive may be non-covered or not considered reasonable or necessary by insurers. You are responsible to pay for these services. We typically bill for office visits, procedure codes specific to Naturopathic services and some codes that may also be used for modalities such as physical therapy, biofeedback, or massage therapy.
  4. Proof of insurance. All patients must complete our patient information form before seeing the doctor. We will make a copy of your driver’s license and current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim.
  5. Claims submission. We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.
  6. Coverage changes. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim in 45 days, the balance will automatically be billed to you.>
  7. Non-payment. If your account is over 90 days past due, you will receive a letter stating that you have 20 days to pay your account in full. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you and your immediate family members may be discharged from this practice.
  8. Missed appointments. It is the policy of Rebel Med Northwest to allow customers to cancel appointments without charge until the end of the business day prior to the day of the appointment. For appointments cancelled on the same day as the appointment, Rebel Med NW will use best efforts to rebook the appointment. If unsuccessful, clients will be charged 50% of the appointment cost unless the cancellation was within 2 hr of the appointment or the customer was “no show, no call” for which the customer will be charged the full price of the appointment. For “same day” booked appointments, customers are allowed a one-hour grace period from time of booking to cancel their appointments without charge. Thereafter, same day cancellation policy rules apply. I authorize Rebel Med Northwest to use the card on file to pay for any outstanding balances, missed appointments, or late cancelations.
  9. Typical Billing Codes:Naturopathic Visits
    • Office visits –99201-99398 We provide and bill for office visits on most visits. Office visit services include provider consultation time spent with you discussing your particular medical issue(s), treatment plan, etc. These charges are easily recognizable on your explanation of benefits as they start with numbers 99. Occasionally, charges for office visits may change your deductible, copay or coinsurance for that particular visit. You may wish to consult your insurance company regarding any changes to your coverage based on a “specialist” office visit.
    • Manual Therapy Codes-97140. Our Naturopathic Physicians also use the manual traction code 97140 for the bill for muscular manipulation work they do. This particular code can also be used by Physical Therapists, Chiropractors and possibly other healthcare professionals. You may wish to check with other providers to see if they are billing this code for your visits.
    • Naturopathic Physical Medicine Codes-(98925-98929);97012;97140,97110. Naturopathic Physicians provide spinal manipulation services (Codes 98925-98929), mechanical traction (97012), manual therapy (97140) and have patients perform specific therapeutic exercises (97110). If you are seeing a physical therapist, chiropractor or other physical medicine providers we recommend having them call us to coordinate care and benefits.
    • Other Codes. Our Naturopathic Physicians also provide Therapeutic ultrasound (97035), Electrical Stimulation(97032), Contrast Hydrotherapy (97034); Injection therapy (96732,J3420,J3415,J3411)
    • Biofeedback – (90901) Biofeedback refers to the use of biofeedback equipment to improve awareness of the nervous system and its effects on health.
    • Massage Therapy – (97124) used for the purpose of massage therapy, as medically necessary, with a prescription, and performed by licensed massage therapists.

I certify that I’m the patient or legal guardian listed below. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to Rebel Med Northwest’s and it’s practitioners. I authorize this office and its staff to examine and treat my condition as the practitioners see fit. I hereby authorize the practitioners to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I’m responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.

I have read and understand the payment policy and agree to abide by its guidelines:

Printed Name of Patient or Responsible Party

________________________________________ ________________________
Signature of Patient or Responsible Party Date


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