Basin Clinic &
Basin Clinic Urgent Care Center

Patient Name:
Chief Complaint/Reason For Visit:
Date of Birth: S.S.#:
Email Address:
Marital Status:
Responsible Party S.S.#:
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Home Phone: Work Phone:
Guardian (if patient is under 18):
Emergency Contact: Phone:
Primary Insurance:

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Dr. Name: Patient Signature:__________________________________

In accordance with the Federal Truth-In-Lending Act, all doctors 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. 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 us and negotiate with your insurance company over disputed claims.

If You Don’t Have Insurance: Our policy requires payment in full at the time of service. We offer a 25% cash discount when paid in full at the time of service. If you cannot make complete payment we require that you make payment arrangements with the receptionist prior to service and make a $100 partial payment on the day service is rendered.

If You Have Insurance: We will be glad to bill your insurance for you as long as we have correct insurance information. We require a one time $50 deposit for new patients with insurance in case the visit is applied to your yearly deductible. We require you as a patient to be responsible for any balance your insurance does not pay. Any balance over 30 days is your responsibility. 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.

Forms of Payment: We accept payment in cash, check, money order, Visa, MasterCard, American Express or Discover. There will be a $30.00 charge on all returned checks.

Delinquent Accounts: Those accounts not paid within 90 days will be turned over to collections or taken to small claims court. We reserve the right to add late charges for delinquent accounts. Should collection be necessary, the responsible party agrees to pay and additional 33% collection fee charged by the collection service and all legal fees of collection, with or without suit, including attorney fees and court costs. We will no longer provide medical care once an account has gone to collection.

Monthly Statements: You will receive an itemized monthly statement until your bill is paid in full whether you have insurance or not. Interest of 1.5% per month will be applied to any amount over 30 days if a payment has been received.

To the extent necessary to determine liability for payment and to obtain reimbursement for this account, I authorize disclosure of portions of the patients record. 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 to Rodney S. Anderson, M.D.; Karl L. Breitenbach, M.D.; Laura B. Arnold, M.D.; Kirk J. Woodward, M.D.; Mike Olsen, M.D.; Amy Olsen, FNP; Aaron Fausett, PA-C; Scott Frisby, PA-C; Michael Wilson, PA-C and Carolyn Henry, LCSW. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered valid as the original. I understand that I am financially responsible for all charges incurred.

I certify that the above information is accurate to the best of my knowledge. I have read and agree to the Financial Policy of this office.