Please correct the errors described below.


I, the undersigned, do hereby authorize the Myofunctional Clinic of Bellevue to use photographs and videos taken during the evaluation and treatment to be used in the following manner as indicated by my initials.

I understand that the above authorization(s) may be rescinded at any time when presented in writing to Nancy K. Magar/The Myofunctional Clinic of Bellevue.


Payment Policy:
I understand payment is expected at the time services are rendered unless medical insurance coverage is through Premera Blue Cross, Regence Blue Shield, Blue Cross Blue Shield of Illinois or Life Wise.
Myofunctional Clinic of Bellevue, PLLC accepts cash, check, and all major credit cards. Payment can be made through the website for Myofunctional Clinic of Bellevue, PLLC through Square payments.

Billing Information:
Prior to the initial evaluation appointment, Myofunctional Clinic of Bellevue, PLLC requires the insurance card in advance of the first appointment. This can be a digital scan of your insurance card or a photo of the card. Any deductible, coinsurance or non-covered services will be the responsibility of the client/caregiver/parent receiving services. This includes any non-payment of fees by the insurance company for any reason, regardless of the Explanation of Benefits (EOB). Statements are sent for the above stated plans when information is received from the insurance companies and payment is expected upon receipt or within 30 days of the receipt of the invoice. I understand that it is my responsibility to notify Myofunctional Clinic of Bellevue of any insurance changes. In the event I have not made the provider aware of the change prior to the time of services, I understand that I am responsible for the services provided. You will be responsible for payment of all services once your insurance coverage has run out, or for any denied claims. Denied claims become your responsibility to pay in full immediately within 30 days, regardless of whether or not you choose to appeal the insurance company’s decision. Appeals are not made by the Myofunctional Clinic of Bellevue. If you appeal and win, and payment is issued to the Myofunctional Clinic of Bellevue, you will be reimbursed immediately.

Referrals and Authorizations:
Due to limited office staff at Myofunctional Clinic of Bellevue, all patients are required to verify coverage benefits and preauthorization requirements prior to having any services performed. I understand that if a referral is required by the insurance carrier, I will be asked to obtain the referral prior to the scheduled appointment. If no referral exists on file or the referral has not been received, the appointment may be cancelled. Myofunctional Clinic of Bellevue will obtain authorization for the evaluation and/or treatment prior to scheduling the appointment when requested by the patient and when applicable. Claims are paid based on medical necessity. Please be aware that authorizations and referrals are not guarantee of payment.

Non-Covered Service Policy:
Certain services performed by Myofunctional Clinic of Bellevue, PLLC are NOT COVERED by insurance plans. I understand that it is suggested that I contact my insurance carrier to verify coverage and benefits. I also understand any non-covered services will be my financial responsibility and payment will be my financial responsibility and payment will be required at time of the scheduled appointment.

Delinquent Accounts Policy:
I understand and agree that regardless of my insurance status, I am ultimately responsible for the balance of my account for professional services. This includes co-insurance, co-payments and non-covered services. If a balance is over 60 days late, a 3.0% monthly interest fee will be added to the outstanding balance. Please inform Myofunctional Clinic of Bellevue, PLLC if payment will be late or if payment arrangements are needed.

I understand that delinquent accounts may be reported to a collection agency following normal collection procedures. If an account is reported to a collection agency, I promise to pay all costs of collection including reasonable attorney’s fees and collection agency costs that may have incurred in the collection process in addition to outstanding balance of account.

Cancellation Policy:
I understand there is a $75.00 charge for cancellations, reschedules or non-attendance (no show) for any appointment without a 24 hours advanced notice. A phone message to (425) 454- 1420 is recommended for 24 hour or less notice. If you are cancelling greater than 48 hours in advance, then an email will be acceptable. Myofunctional Clinic of Bellevue, PLLC understands that unusual circumstances may arise, and fees may be waived at the discretion of administration. It is preferred that if a patient has a fever, cough or not feeling well to cancel their appointment and not risk infecting others.

Late Arrival:
I understand arriving promptly for the scheduled appointment is required. I also understand that I am charged the full amount for the scheduled session, regardless of my arrival time. If you arrive more than 10 minutes late for your appointment it is important to understand that you can still be seen but only for the remainder of your scheduled session and the fee remains the same. I also understand that sometimes certain situations and emergencies can occur and cause the clinician to be tardy. I understand that if the clinician is tardy, I will receive a makeup of the time that was not provided. Therapy sessions are typically booked in 30 minute slots with 1:1 therapy time at 25 minutes and rest of time for administrative work.


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