patient information
New Patient Forms
- Patient History (pdf)
- Payment Information (pdf)
- Patient Profile (pdf)
All forms require Adobe Reader to view and print.
Insurance and Billing Information
Please be sure to bring the following to your office visit:
- Insurance card
- Identification
- List of Medications
- Referral (if necessary)
- Completed Medical History Form (click on the link to print a blank form)
We accept the following insurance plans:
- Aetna
- Community Health Plan of Washington
- First Choice Health Network
- Group Health Cooperative
- Medicare / Medicaid
- One Health Plan of Washington
- PacifiCare / Secure Horizons
- Premera Blue Cross
- Regence BlueShield
Whenever possible, we will bill your insurance company for you. If we have a contract with your insurance plan, you will receive a billing statement from us after the insurance company has processed your claim. Your charges will be listed along with any payments received from your insurance company. The listing should correspond to the explanation of benefits you will receive from your insurance company.
Remember, it is up to you to familiarize yourself with your insurance benefits. Your health plan mandates that you are financially responsible for payment of all co-pays, deductibles, and non-covered services. Northwest Urology is contractually obliged to collect them, please do not request that we adjust these from your account.
Courtesy Billing
If we are not contracted with your insurance company, we can submit courtesy billings for you.
Courtesy billing is a service we provide for our patients. You are still financially responsible for your account and you will continue to receive a monthly statement until your account is paid in full.
Billing Statements
Each member of your family will receive, as necessary, an individual billing statement on a monthly basis. Your statement includes information necessary for your personal records. The balance on your statement is subject to a finance charge after 60 days.
When you make a payment, please include the top portion of your billing statement. This contains information that helps us to process your payment quickly and accurately. If you are making a payment for more than one family member, please include the top portion of each statement.
We make every effort to process your charges efficiently. In the event that an error does occur, please bring it to our attention as soon as possible by calling (360) 848-8783 .
Fees
Northwest Urology Clinic’s fees are based on the types of services provided and are competitive for this region. Our fees are public information. Whenever possible, we will supply you with a range of fees for particular services or an estimate of charges for surgical procedures. Please keep in mind that these are estimates. Your actual cost may vary depending on your particular situation.
Payment Policy
We have faith in your integrity and financial ability to meet obligations. To maintain your account in good standing we ask that:
- All charges are due and payable within 30 days of receipt of your statement
- Regardless of your insurance coverage, you are responsible for the timely resolution of your account balance
- If your claims are delayed, please stay in contact with us, and your insurance company to expedite processing
For your convenience, we accept Visa, MasterCard, and American Express, as well as your personal check. A $25 processing fee will be applied to your account if your check is returned by the bank. We discourage sending cash by mail.
Since our managed care contracts require collection of co-payments for each visit, a billing fee of $15 will be charged to any co-pays not paid at the time of service.
Financial Services
We understand there are circumstances that may warrant an extended payment plan. If you need to request special consideration, please call (360) 848-8783 or email our Patient Accounts Representative to discuss your payment options. We will work with you to find a satisfactory resolution to your particular situation.
