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Client Information

Emergency Contact Information

Insurance Information

HIPPA Disclosures

Medical History

Any established patient who fails to show or cancels/reschedules an appointment and has not contacted our office with at least 24 hours’ notice will be considered a no show and charged a $75.00 fee. If a third No Show or cancellation/reschedule with no 24-hour notice should occur, the patient may be dismissed from Rainier Behavioral Health. Any new patient who fails to show for their initial visit may not be rescheduled. The no show/cancellation fee is charged to the patient, not the insurance company, and is due at the time of the patient’s next office visit. As a courtesy we make reminder calls for appointments. Even if you do not receive a reminder call or text message, the above Policy will remain in effect. We understand there may be times when an unforeseen emergency occurs. If you should experience extenuating circumstances please contact our Practice Manager, who may be able to waive the No Show fee. You may contact Rainier Behavioral Health, should it be after regular business hours Monday through Friday, or a weekend, you may leave a message. Often the assumption is made that if a person has insurance, then it is the insurance company who owes the doctor for their services. As the insurance contract is between you and the insurance company alone, it is you who are responsible for the bill, regardless of insurance coverage determination. We are happy to bill your primary or secondary insurance company for you as a courtesy. Please keep in mind that the responsibility for the payment remains with the patient. IF YOU ARE COVERED BY INSURANCE Clients with insurance are expected to make copays at time of service and deductible amounts/co-insurance as claims are processed. It is your responsibility to know the terms of your insurance coverage, as well as any exclusion, limitations, deductibles and copays. We do our best to provide you with the information we gather from your insurance carrier, but it is not a guarantee of payment from your insurance carrier. IF YOU ARE NOT COVERED BY INSURANCE Patients without insurance are expected to make payment in full for all charges at the time of service. If you pay in-full at the time of services, a 5% discount will apply for all payments. Keep in mind that sessions with the clinician may change in the type of treatment i.e. Therapy, therapy with medication management, just medication management, etc. This may result in different session fees. If you have any questions regarding the type of sessions you are receiving, please ask. PAYMENT OPTIONS Payments may be made with Visa, MasterCard, Discover, Debit Card, cash, money order or personal check. There will be a $40.00 fee on all returned checks unpaid by your bank. PAST DUE ACCOUNTS As a valued client we will work with you to clear up overdue accounts however; we reserve the right to utilize a collection agency for recovery efforts. If patients are sent to collections for unpaid charges, they will be terminated from the practice. AUTHORIZATION/ACKNOWLEDGEMENT With my electronic signature below, I hereby authorize release of any relevant information necessary to process my claim to my insurance company. I also authorize any insurance benefits otherwise payable to me to be paid directly to Rainier Behavioral Health for providing the services.

* I acknowledge I have read the financial policy above and that I am responsible for all charges regardless of any insurance coverage I have. I understand that delinquent accounts may be assigned to a credit reporting collection agency and agree to pay for all legal costs and expenses including reasonable attorney fees. By signing this Acknowledgement, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.

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