Basin Clinic &
Basin Clinic Urgent Care Center

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In accordance with the Federal Truth-In-Lending Act, all providers are required to give their patients complete information in connection with the extension of credit.

Basin Clinic Policy: The patient is responsible for all medical bills. We bill your insurance as a courtesy. Payment is expected within 30 days of date of service. Our staff will help with completion of insurance forms. It is the patient's responsibility to know their contract benefits, assure collection of insurance payments to Basin Clinic and negotiate with your insurance company over disputed claims.

If You Do NOT Have Insurance: Our policy requires payment in full at time of service. If you can't make complete payment, we require that you make payment arrangements with the receptionist prior to services and make partial payment including a $50 deposit on the date of service.

If You Have Insurance: It is your responsibility to provide us with the correct insurance information. We will bill your insurance for you as long as we have the correct insurance information. However, we require you as a patient to be responsible for any balance your insurance does not pay. Any balance over 30 days is the patients responsibility. Waiting for the insurance payment is a courtesy and it may be withdrawn under certain circumstances. This office does not warrant or guarantee that your insurance company will pay, nor do we promise that an insurance company will pay the fees charged. Insurance policies are an arrangement between the insurance carrier and the patient/insured. If we are a provider for your insurance, be aware that if the patient needs to be referred to another doctor or hospital, that provider may not be a preferred provider for your insurance and the patient/policy holder will be responsible for any amount not paid by their insurance to that non-preferred provider.

If You Have Medicare: We will bill Medicare for you, but due to the length of time for reimbursement, we do ask that you monitor your statement to see that nothing is missed and to inform us if something needs re-billed.

If You Have Medicaid: We require you to pay the co-payment on the date of service. A statement will not be mailed for unpaid co-payments. A hold will be placed on your account and future appointments will not be scheduled until the unpaid co-payment is paid in full.

Co-payments, Deductibles and Non-covered Benefits: As a patient, it is your responsibility to take care of the co-payments or deductible on the date of service. Any non-covered service shall be paid within 30 days of the date of service.

Missed Appointment Policy: We require that you notify us at least 24 hours in advance as to any appointment changes. There will be a missed appointment fee of $25.00 for the first missed appointment. Missed appointment fees will be increased by $25.00 for each additional missed appointment. Future appointments will not be scheduled until all previous missed appointment fees are paid in full.

Forms Of Payment: We accept payment in cash, check, money order, or credit card. There will be a $20.00 charge on all returned checks.

Delinquent Accounts: Accounts not paid within 60 days will be placed in an in-office collection hold, turned over to a collection agency, or taken to small claims court. This action may negatively impact your credit score. We reserve the right to add charges for delinquent accounts, including the cost of sending notification via priority mail, up to a 33.33% collection fee, attorney and court costs and any additional collection fees obtained by our third party collection agency. I authorize disclosure of portions of the patient's records to the extent necessary to determine liability for payment and to obtain reimbursement should this account be turned over to collections.

Monthly Statements: You will receive an itemized monthly statement until your bill is paid in full, placed in an in-office collection hold, or turned over to a collection agency, whether you have insurance or not.

Assignment of Benefits: I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled including, Medicare, private insurance, and other health plans. This assignment is to be considered as valid as the original. I understand that an insured retains ultimate responsibility for paying for health care services received. I understand that I am financially responsible for all charges whether or not paid by said insurance.

I have read and fully understand the financial office policy and agree to abide by these terms.

Signature___________________________________Date___________________