We thank you for choosing Rebel Med Northwest. We ask all our patients to read and agree to our Financial Policy. We are happy to answer any questions you may have before you sign this. Unfortunately, patients who refuse to sign this are not able to be seen and will be subject to our appointment cancellation policy and fee.

We understand that health care and health insurance are very expensive, and we want you to receive the benefits and services from your insurance to which you are entitled. However, your insurance is a contract between you and your insurance company (and sometimes your employer). We have no control over what your specific insurance plan will cover and what they won’t. In fact, it is not uncommon for insurance companies to cover something for one month, and then decide not to cover it the next month. This is particularly true of non-Washington-based insurances.

It has become increasingly time-consuming for our office to argue with insurance companies on your behalf to get them to pay your claim. If we have to spend time doing that, it means that other patients who need medical attention from us may not receive it. That “other” patient who needs us could one day be you or a family member.

In order to streamline our billing and payment system, Rebel Med Northwest requires that ALL patients have a valid credit card on file or leave a retainer. There are no exceptions to this rule. The credit card will be swiped today and kept on-file using the latest end-to-end encryption security software that our vendor Bluefin uses. Our office is “PCI-compliant”, which means that we place a high priority on the security of cardholder data.

We will submit your claim to your insurance, and if your insurance tells us that you have a deductible or co-insurance, or if there is a non-covered portion of your bill, or if your insurance only partially pays your claim or denies it completely, then we will automatically bill your balance to the credit card on file. We will NOT contact you first to request your authorization. Your signature on the next page IS your authorization. Please feel free to ask one of our assistants in advance if you would like an estimate of what the charges may be. The reason why we can only estimate is that we do not set the payment rates, the various insurance plans do, and they can vary.

It is imperative that if you subscribe to an insurance plan which requires a referral or preauthorization, that you have one on file at the time of your visit. This is YOUR responsibility, not Rebel Med Northwest’s, although we are happy to assist you if we can. Again, if we are spending our time trying to track down your referrals for you, then it means we have to spend less time with other patients who need us. Many insurance companies will deny your claim permanently if your referral is not authorized within 30-60 days. If your insurance denies your claim because of this, then we will automatically bill your credit card on le for the approximate amount that an insurance company would have paid, had the referral been authorized. If your insurance company eventually pays your claim, then we will gladly refund you the amount they paid, once the payment has been posted.

Laboratory services (like bloodwork) and pathology services are performed by outside laboratories which are financially independent of our office. In the case of pathology services, we will send along all of the insurance information that you give us and the pathology lab will attempt to bill your insurance directly. However, there may be pathology services that your insurance will not cover. Feel free to discuss this directly with the pathology lab and/or your insurance company if you have questions.

If the credit card we have on file for your changes, please notify us IMMEDIATELY, by calling us. It is not uncommon for people to change or cancel their credit cards for various reasons, including when a credit card expires. That is quite understandable. If we run your credit card and it is denied for any reason, we reserve the right to charge an additional $25 administrative fee if we are not able to run a new credit card within 7 days. This is similar to the $25 fee that we also charge for returned checks. We will contact you or leave you a phone message on the phone number you provided for us, asking you to give us a call with the new number right away. We will key-in the new credit card number into your le, and that will become your new card on- le, subject to the same financial policy as the card you gave us in-person when you were in our office.

Finally, when patients make appointments and then either “no show”, or cancel them with less than one business day’s notice, it means that other patients who want to be seen as soon as possible, can’t. We do not double-book appointment slots, which means that time allotted to you goes unused and could have been given to someone else. Therefore, we reserve the right to charge for missed appointments in the range of $75-$100 per visit per patient when not canceled more than one business day in advance. Calling our voicemail over the weekend when the office is closed and canceling your visit for the following Monday is considered less than one business day’s notice and subject to our cancellation policy.

Accounts which are past due beyond 60-days are subject to a 1% per month interest charge. In addition, accounts which are more than 90- days past due may be subject to an additional $25 processing fee, in addition to the interest charge, and may go to collections. If the account goes to collections, your national credit rating may be affected. Luckily it is extremely rare for an account to go to collections. We will make every effort to work with you to get your balance paid in full. Temporary financial set back can happen to anyone, and we are happy to privately and confidentially work out a payment plan with you that works for you and for us. Please feel free to discuss this with our billing manager. We don’t want finances to ever come in the way of you or your family members from getting the best medical care possible!

Rebel Med Northwest’s primary purpose is to take care of patients and their families. That’s it. We hope you now have a clear understanding of our financial policies. These policies exist for one reason only: so that we can concentrate on taking care of patients’ medical needs, rather than dealing with insurance companies or trying to track down patients for unpaid bills. We hope you will agree that the policies we have benefited everyone, and will, in the long run, help to deliver less expensive yet high-quality health care, which we all strive for in this country.

Pre-Authorized Healthcare Form
By Electronically signing below, I agree to all of Rebel Med Northwest’s Financial Policy, and I authorize Rebel Med Northwest (RMNW) to keep my signature and a valid credit card number securely on file in my account. I allow RMNW to automatically charge my credit card for any outstanding balances. These may include insurance denials for ANY reason (including no referral on file); missed or canceled appointments; deductibles; co-insurances; partially paid claims; cosmetic procedures; as well as other reasons which may arise.

If the credit card that I give today changes, expires, or is denied for any reason, then I agree to immediately give RMNW a new, valid credit card which I will allow them to key-in over the phone. Even though RMNW is not swiping this card in person, I agree that the new card will still be subject to the Financial policy listed herewith and may be used with the same authorization as the original card which I presented in person. In addition, I agree not to initiate or pursue a chargeback or payment reversal after RMNW has charged my credit card for any of the above reasons.

I understand that I am responsible for payment for all medical services provided to me by RMNW. I understand that my insurance may deny or delay payment for these services or only partially pay them, and I agree to allow RMNW to immediately charge my credit card on file for the balance if that happens. I understand that this form is valid until I cancel this authorization through written notice to Rebel Med Northwest.

By clicking the checkmark, I acknowledge I have read the above information. By signing electronically, I hereby acknowledge and consent to treatment at this facility, and agree to the above financial policies.

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