Thank you for choosing Revive Innovative Healthcare PLLC. We ask all our patients to read and agree to our Financial Policy. We are happy to answer any questions you may have before you sign this. The purpose of the policy is to help insure that we can focus on your care and to be transparent concerning finances. Unfortunately, patients who refuse to sign this are not able to be seen and will be subject to our appointment cancellation policy and fee. Health care and health insurance are expensive. We want you to receive the services and benefits to which you are entitled. It is not possible for us to know what each policy covers or does not cover. It is your responsibility to contact your insurance provider and verify what services are covered.
In order to streamline our billing and payment system, Revive Innovative Healthcare requires that ALL patients have a valid credit/debit card on file or leave a retainer. There are no exceptions to this rule. The credit/debit card will be swiped (or entered in via the online service) the day of service and kept on-file using the latest end-to-end encryption security software. Our office is “PCI-compliant”, which means that we place a high priority on the security of cardholder data.
Insurance: We are in the process of credentialing with insurance providers in the state of Washington. As such, our service may be covered as out of network services. We will provide you with a superbill that you can submit to your insurance company. It is not possible for us to know if, how much, or for what services, they may cover. Check with your insurance provider before your appointment. Payment in full is due time of service.
When insurance credentialing is complete, and if we are enrolled in your policy, we will bill your insurance on your behalf. If your insurance tells us that you have a deductible or coinsurance, or if there is a non-covered portion of your bill, or if your insurance only partially pays your claim or denies it completely, then we will automatically bill your balance to the credit card on file. We will NOT contact you first to request your authorization. Your signature on the next page IS your authorization. Please feel free to ask one of our assistants in advance if you would like an estimate of what the charges may be. The reason why we can only estimate is that we do not set the payment rates, the various insurance plans do, and they can vary.
Self-pay discounts: We offer the following discounts for self-pay patients if payment is made in full at time of service. These discounts apply to physician services only, and not to billable supplies. Only one discount will apply.
10% Paid in full at time of service
15% Medicare, Tricare, Veterans if paid in full at time of service
Applies to physician services only -- discount does not apply to tests, supplies, additional procedures or materials used
40% income based assistance (Applies to physician services only -- discount does not apply to tests, supplies, minor surgery, additional procedures, or materials used). We offer a 20% discount on most minor surgical procedures.
for patients with a household income less than or equal to 150% of the United States Federal Poverty Level.
Documentation that may be required includes:
Tax returns from last year for ALL members of the payers household over the age of 18
Last two pay stubs, our proof unemployment payments for all members of the payers household over the age of 18
In order to receive the discount, 75% of the total bill, at the reduced rate, is due at time of service. The remainder is due within 30 days of service.
Application for Income Based Assistance must be made prior to the appointment.
It is imperative that if you subscribe to an insurance plan which requires a referral or preauthorization, that you have one on file at the time of your visit. This is YOUR responsibility, not Revive Innovative Healthcare’s, although we are happy to assist you if we can. Many insurance companies will deny your claim permanently if your referral is not authorized within 30-60 days. If your insurance denies your claim because of this, then we will automatically bill your credit card on le for the approximate amount that an insurance company would have paid had the referral been authorized. If your insurance company eventually pays your claim, then we will gladly refund you the amount they paid, once the payment has been posted.
Laboratory services (such as bloodwork) and pathology services: We offer a selection labs that are collected in office. Payment in full for lab services is required at time of service. Membership rates are available to Revive Family Medical's Direct Primary Care members. For labs that are not performed in office, or if you prefer, we will write orders for them to be performed by outside laboratories which are financially independent of our office. In the case of pathology services, we will send along all of the insurance information that you give us and the pathology lab will attempt to bill your insurance directly. However, there may be pathology services that your insurance will not cover. Feel free to discuss this directly with the pathology lab and/or your insurance company if you have questions.
If the credit card we have on file for you changes, or expires, please notify us immediately by calling us. If we run your credit card and it is denied for any reason, we reserve the right to charge an additional $25 administrative fee if we are not able to run a new credit card within 7 days. This is similar to the $25 fee that we also charge for returned checks. We will contact you or leave you a phone message on the phone number you provided for us, asking you to give us a call with the new number right away. We will key-in the new credit card number into your le, and that will become your new card on- le, subject to the same financial policy as the card you gave us in-person when you were in our office.
Cancellation/No show policy: In order not to be charged a cancelation fee, you must cancel at least one business day prior to your scheduled appoint., We do not double-book appointments, which means that time allotted to you goes unused and could have been given to someone else. Therefore, we reserve the right to charge for missed appointments in the range of $75-$100 per visit per patient (depending on the type of appointment scheduled) when not canceled more than one business day in advance. Leaving voicemail or email over the weekend when the office is closed and canceling your visit for the following Monday or holiday is considered less than one business day’s notice and subject to our cancellation policy.
Accounts which are past due beyond 60 days are subject to a 1% per month interest charge. In addition, accounts which are more than 90 days past due may be subject to an additional $25 processing fee, in addition to the interest charge, and may go to collections. It is extremely rare for an account to go to collections. We will make every effort to work with you to get your balance paid in full. Temporary financial setbacks can happen to anyone, and we are happy to privately and confidentially work out a payment plan with you that works for you and for us. Please feel free to discuss this with our office. We don’t want finances to ever come in the way of you or your family members from getting the best medical care possible!
Our primary purpose is to take care of patients and their families. These policies exist for one reason only: so that we can concentrate on taking care of patients’ medical needs.
You will be asked to electronically sign the following before your first appointment. An electronic copy will be sent with you intake paperwork.
Pre-Authorized Healthcare Form By Electronically signing below, I agree to all of Revive Innovative Healthcare’s Financial Policy, and I authorize Revive Innovative Healthcare to keep my signature and a valid credit/debit card number securely on file in my account. I allow Revive Innovative Healthcare to automatically charge my credit card for any outstanding balances. These may include insurance denials for ANY reason (including no referral on file); missed or canceled appointments; deductibles; co-insurances; partially paid claims; cosmetic procedures; as well as other reasons which may arise.
If the credit card that I give today changes, expires, or is denied for any reason, then I agree to immediately give Revive Innovative Healthcare a new, valid credit/debit card which I will allow them to key-in over the phone. Even though Revive Innovative Healthcare is not swiping this card in person, I agree that the new card will still be subject to the Financial policy listed herewith and may be used with the same authorization as the original card which I presented in person or entered on the online portal. In addition, I agree not to initiate or pursue a chargeback or payment reversal after Revie Innovative Healthcare has charged my credit card for any of the above reasons. I understand that I am responsible for payment for all medical services provided to me by Revive Innovative Healthcare. I understand that my insurance may deny or delay payment for these services or only partially pay them, and I agree to allow Revive Innovative Healthcare to immediately charge my credit card on file for the balance if that happens. I understand that this form is valid until I cancel this authorization through written notice to Revive Innovative Healthcare.
I acknowledge I have read the above information. By signing electronically, I hereby acknowledge and consent to treatment with Revive Innovative Healthcare, and agree to the above financial policies.