To help serve you better, I list guidelines and office policies here. Please download and read the agreement below. Sign the Client Acknowledgement on the reverse side and bring this form with you to your first treatment.

Financial agreement

Fees

I offer a discount from my usual and customary fees if you pay me directly at the time of service and I will not be providing the service of billing your insurance company. (See Payment at Time of Service Discount column below.)

All herbal supplements are charged separately.

Payment Method

I accept payment by cash, check or credit/debit card. There is a $35.00 fee for a bounced check and only one occurrence is permitted. If a second check bounces, I will require cash-only payment from then on.

Cancellation and Lateness Policy

If you are unable to keep your appointment for any reason, I ask that you call my office at least 24 hours in advance to cancel or reschedule the appointment. Otherwise you will be charged a $75.00 fee for the missed appointment. If you are 20 or more minutes late, your appointment will be cancelled and you will be charged a $75.00 fee for the reserved appointment time.

Insurance

Most insurance plans in the State of Washington cover acupuncture. Call your company to find out if you have acupuncture benefits.

I am a preferred provider with several insurance companies. I will bill the following insurance plans directly:

• Premera Blue Cross, Premera Lifewise Health Plan of Washington
• Uniform Medical Plan
• First Choice Health Network (which includes many small insurance plans)
• Aetna
• Cigna
• United
• PIP/Auto Injury

If you have insurance with a company other than the ones listed above, check with your company to see if they will allow you to see ‘out of network’ providers.

If you would like me to bill your insurance company, you will be responsible for the portion your insurance company states is "patient responsibility" (copays, coinsurance, etc.).

Please bring your insurance card with you to your first appointment. As a courtesy, I will call once to verify your benefits with your insurance company. I strongly suggest that you call the number on the back of your insurance card and verify your own acupuncture benefits.

The information your insurance company gives you or me regarding your benefits is not a guarantee of payment. Actual benefits are determined once your provider sends the claims to your insurance company in writing. If, for some reason, your insurance company does not pay for your treatment, you will be responsible for all fees.

If you have a copay, it is due at the time of service. I will bill you after I receive notification from your insurance company for the portion, if any, in addition to your copay that they determine is your responsibility.

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