Rehabilitation Options of Issaquah Patient Registration

Rehabilitation Options of Issaquah - Financial Policy

We would like to share the following policies with you so that you understand your responsibility regarding the charges for the services rendered to you by this office.

  1. If we participate (are contracted) with a commercial insurance plan under which you are covered, we will bill the carrier for all charges for all covered, medically necessary services rendered. We will bill, both your primary and secondary insurance plans for contracted plans. You will be responsible at the time of service for payment of your co payment. There is a $25.00 billing fee for each missed co pay.
  2. If we do not receive payment from your primary carrier for any reason, within 60 days of filing, you are responsible the entire amount. If you have a past due balance on your account you will not be permitted to schedule any additional appointments.
  3. For patients with auto related injuries please note the following:
    We will bill your Personal Injury Protection (PIP) insurance through YOUR automobile insurance for an auto related injury. We do not bill third parties (i.e. the liable party). We must be able to verify that your PIP coverage is open and active prior to treatment. In addition to verifying you have active PIP coverage we will also collect your private health insurance information. If you do not have private health insurance, or if it is with a company we are not contracted with, we will require a $500 deposit. This will be reimbursed to you upon completion of care and payment of all medical services rendered.
  4. For patients with a worker’s compensation claim: If your claim is denied, the patient is responsible to provide us with current health care insurance information or pay the balance in full.
  5. Please be aware that some, and perhaps all, services provided may be considered as not being reasonable and necessary under your medical plan benefits. You are responsible for payment regardless of any insurance company’s determination. This pertains to ALL insurances (motor vehicle included.)
  6. If you need to cancel an appointment we require that you call 24 hours in advance. Appointments are in high demand, and your early cancellation will give another person the possibility to have access to timely medical care. There will be a $50.00 no-show fee for any appointments not cancelled at least 24 hours prior to the scheduled appointment time. This fee will not be paid by private insurance, L&I, or PIP coverage. This fee is for all departments at ROI. All no show fees must be paid in full before next appointment is scheduled. We do confirmation calls as a courtesy but they are not a guarantee. Please keep track of your scheduled appointment times. We reserve the right to discharge any patient that misses 3 scheduled appointments without giving 24 hour notice.
  7. Your signature below signifies that you have read, and understand your responsibility regarding charges incurred in this office.

Rehabilitation Options of Issaquah - Medication Policy

  1. Refills requests must be made 72 hours in advance for all medication. Pain medications cannot be refilled on weekends, Friday night, Sat-Sunday.
  2. Medication prescriptions are provided to last until your next appointment.
  3. Patients must be seen at least every three months if prescriptions are going to be written. However, many patients will require sooner follow up.
  4. Urgent medication or medical issues can be discussed by calling the on-call number and non-pain medication refills may be prescribed as needed. Requests for new medications or changes in dosage must be discussed while seeing physician. The office staff cannot discuss new medications or change requests after your appointment is complete.
  5. Patients receiving pain medication and who need to be seen in the ER or another physician in an urgent basis- must notify the other physicians of their relationship with Rehab Options of Issaquah.
  6. Physicians cannot write me prescriptions out of state.
  7. Lost or stolen prescriptions will not be replaced.
  8. Medications will only be refilled early for special circumstances and only at a patient visit.
  9. All prescriptions must be filled at the same pharmacy.
  10. All prescriptions must be taken as prescribed.
  11. Routine urine drug tests will be performed on patients being prescribed controlled substances (narcotic, benzodiazepines, etc). This will include a urine drugs screen prior to receiving an initial prescription.
Patient Name
Today's Date
Electronic Signature: Please type "I agree" here if you agree to all the terms and conditions above.

By clicking 'Continue' you agree to our financial and medication policy.

Patient's Employment Info

Emergency Contact

Responsible Party Information if different than the patient

Primary Insurance Information

Secondary Insurance Information

If you are not the subscriber do you give us permission to discuss your account with them? Yes or No

Insurance Authorization and Assignment

I attest that the information I have given is correct and true to the best of my knowledge. I hereby assign benefits to Rehabilitation Options of Issaquah and authorize them to furnish information regarding my illness to my insurance company. I understand that I am responsible for any amount not paid for by my insurance.

 Patients Registration

Wordpress services by Tailored WP