Pullman Family Medicine
915 NE Valley Rd
Pullman, WA 99163
Phone: (509) 332-3548
Fax: (509) 332-5253

Financial Policy

Translate:


Fill-out the form below and then print it out. Your information will not be saved or sent.

Pullman Family Medicine is committed to providing the highest level of quality medical care and personal service to our patients. We do not discriminate in the provision of services because of inability to pay or based upon race, color, sex, national origin, disability, religion, age or sexual orientation. For every commitment, there is an obligation.  We feel it is the patient or guardians’ responsibility to meet their financial obligations. We see patients from many different insurance plans; as such, it is impossible for us to know all the covered benefits, co-pays, and deductibles for each plan.  In addition, your insurance company will not guarantee payment to us.  While it is our intention to assist you, it is still your responsibility to ensure that all services rendered or referred by Pullman Family Medicine on your behalf are paid in full.  In order to clarify Pullman Regional Hospital Clinic Network, LLC DBA Pullman Family Medicine’s Financial Policy, we have listed our financial requirements below:


Patients without Insurance Coverage

Upon check in, patients will be asked to pay $75 dollars up front and the remainder at the end of the visit. Payment in full at the time of service is expected.  We offer a 20% discount to patients who pay for their services in full at the time of their visit. If absolutely necessary short-term payment plans are available, but must be requested prior to the services being performed.  Patients on payment plans will be expected to pay at least ½ on the date of service and then the remainder may be split into equal monthly payments, not to exceed six months.


Contracted, PPO & HMO Patients that have a Co-payment or Deductible

We will bill your insurance for you.  If your insurance plan has an annual out-of-pocket deductible, you will be expected to pay at time of service until that deductible is met. Co-pays must be paid at the time of service, as required by your insurance company. If the Co-pay is not paid within the same day of appointment, then a $10 fee will be assessed.  Once your claim is processed by your insurance, any additional co-insurance, deductibles, or non-covered services will be due upon receipt. If you are unable to pay the balance in full, payment arrangements may be available by contacting the billing office directly at (509) 332-6139.


Medicare Patients

We will bill Medicare for you.  You will receive a statement after Medicare has paid their portion of the charges or applied them to your deductible.  If you have supplemental insurance to Medicare, we will also bill your Medicare Supplement for you.  You will receive a statement from our office after Medicare and your secondary insurance has paid their portion of the charges or applied them to your deductible.  Occasionally Medicare Supplement insurances will pay the payment directly to you.  In this case, please contact our office immediately or send the check to us so that we can keep your account current. 


Medicaid Patients

We accept patients on the Washington State Medicaid Programs that are assigned to Pullman Family Medicine only.  Patients on Medicaid and affiliated health plans are required to present a current medical identification card and other insurance information upon arrival at each visit.  If you do not have all of your current insurance cards, you may be asked to reschedule your appointment. Medicaid patients being seen for non-covered medical services will be expected to pay in full at time of service.

Non-contracted Insurance/Private Insurances

Upon check in, patients will be asked to pay $75 dollars up front and the remainder at the end of the visit. As a courtesy to all our patients, we will bill your primary insurance for you; however, you are responsible for full payment of your account.  You are expected to pay in full at time of service.  


Auto Accidents, Civil Suits, Home or Business Owners Claims

Due to the often-lengthy resolution of these claims, you are expected to pay in full for any charges that are not paid in full by your insurance within 30 days. We will bill your third party insurance one time as a courtesy if you supply all of the necessary billing and contact information.


Worker’s Compensation Claims

If you are seeing one of our providers for an injury that occurred during the course of your employment, please be sure to notify the receptionist that your injury is “work-related” so we can make sure we get the appropriate paperwork filled out.  We have the paperwork for the State of Washington Labor & Industries here in our office for you to fill out.  If your employer is self-insured with another carrier please bring the appropriate paperwork with you from your employer and notify the receptionist that it is a different carrier.  Please be advised that our office is required by law to report all work-related injuries.  We cannot choose not to report the accident if we have knowledge that it is work-related.  If your employer or their insurance carrier denies the claim, you will be held financially responsible for all charges.  We are contracted with WA Department of Labor & Industries and the Idaho State Insurance Fund.  If your employer is not covered by either of these carriers, please check with them in regards to any restrictions in who you may see for your claim.


Obstetrical Patients

Because obstetrical care for visits and delivery is not billed out until after the delivery, you will be required to make monthly payments during your prenatal care for any amounts not covered by your insurance company.  Our office will work with your insurance company to determine an estimated patient amount due.  We will contact you to work out a payment plan, with the intention of having the estimated portion due paid prior to delivery.  Please contact Pullman Regional Hospital to set up any special arrangements for Hospital payment they may require.


Services Provided to Minors

A “minor” is defined as someone under the age of eighteen years of age, who is not considered legally emancipated from his or her parent or guardian.  We realize that there may be an arrangement regarding who is responsible when paying for medical services provided to a minor.  However, it is our policy that the parent or guardian who requests medical care for the minor is the financially responsible party. 


Laboratory and Other Ancillary Services

Pullman Family Medicine provides some lab services in the office. In addition, several test specimens are drawn or collected here and then sent to an outside laboratory or pathologist for processing.  In addition, ultrasounds are often sent to an outside radiologist for the interpretation and report.  You will receive a separate statement of charges for services provided outside our office.  An example of these services would include:  Laboratory charges, pathology for special tests ordered, specimen evaluation, radiological services, etc. 


Students/Short-term patients

If you would like we can send your statements and any correspondence to an alternate address (i.e., parents, permanent address etc.), however be advised that the mail will still be addressed to you if you are over eighteen and you will still be held financially responsible for any charges incurred.  In addition, you will still be required to pay any co-pays at the time of service.


Collection Accounts, Administrative Fees and No-Show/Late Cancellation Fees

There will be a $25.00 fee for all no-show appointments and late cancellations cancelled less than 2 hours’ notice. NSF checks will be charged $35.00. If your account is sent to collections due to non-payment, it will be referred to an outside collection agency.  In addition, Pullman Regional Hospital Clinic Network LLC DBA Pullman Family Medicine reserves the right to terminate the doctor-patient relationship if your account is sent to collections. 

I read and understand the information above. If bills remain unpaid without previous payment arrangements, Pullman Regional Hospital Clinic Network, LLC DBA Pullman Family Medicine may initiate collection procedures and/or legal actions, which will necessitate the release of confidential information for dates and types of services rendered. I agree to reimburse Pullman Regional Hospital Clinic Network, LLC the fees of any collection agency, which may be based on a percentage at the maximum of 40% of the debt, and all costs, and expenses, including reasonable attorneys’ fees, we incur in such collection effort. I hereby release Pullman Regional Hospital Clinic Network, LLC DBA Pullman Family Medicine from all liability arising therefrom.


I understand that I am financially responsible for all charges whether or not paid by my insurance company. I, the undersigned, authorize treatment and request payment of authorized Medicare & Medicaid services and/or other insurance benefits be made payable on my behalf to Pullman Regional Hospital Clinic Network, LLC DBA Pullman Family Medicine for any services furnished to me or my dependents by Pullman Family Medicine or its affiliates. I authorize the holder of medical information about my dependents or me to release to the Centers for Medicare & Medicaid Services (CMS), its agents, and/or my current insurance company or any subsequent insurance companies from which I obtain coverage, any information needed to determine these benefits or the benefits payable for related services. If “other health insurance” is indicated, my signature authorizes release of the information to the insurer or agency shown.


Patient’s Name:
Date of Birth:
Relationship to Patient:
Signature: (Patient, Parent, Guardian, or legally authorized individual signature)
Date:
Printed name if signed on behalf of the patient:

Revised: 04/1/17


CLICK HERE TO PRINT THIS PAGE