With whom may we discuss care:
With my signature below, I acknowledge and understand that this information will be kept in my medical record according to and the instructions above will be honored until revoked by me in writing. It is my responsibility to notify GPC should I change one or more of the telephone numbers listed above.
Greenlake Primary Care Financial Policy(updated 1/2021)
Greenlake Primary Care does not participate with any private insurance which means we will not bill any private insurance on your behalf.
As a patient, you can expect that we will:
As a patient or guarantor, this is what we ask of you:
For your convenience we accept both Visa and Master Card, and ACH payments (through HINT only)
Checks returned for insufficient funds will result in an immediate charge of $35.00 against your account.
We require at least 24-hour notice if you are unable to keep your appointment. Missing an appointment without notice and/or late cancel is considered a no show. Repeated no shows may result in a charge of up to $50.00 ($175 for psychiatric appointments A third no show within 12 months may result in dismissal from the practice.
Questions about your account can be answered by Naomi Busch, MD (206)5245656
Credit Card Authorization:
I authorize Greenlake Primary Care to charge my credit on file for both my monthly fee as well as incidental charges. These include charges collected for labs, medications, late fees as above, and other incidentals that will be explained to me prior to any payments being rendered. Credit card numbers and ACH will be entered directly by me or staff into the secure payment system HINT or directly into our online credit card terminal through Transaction Express. No card numbers or bank information is stored in my chart or in the office and the card number, cannot be accessed once entered.
I understand that Greenlake Primary Care does not bill insurance, and therefore will not release my information to any health insurance company unless directed by me with written notification.
When patients turn 18 years old, they become the guarantors of their account. They will be asked to review their own financial agreements the first time they have a visit after turning 18.
I have read and understand this policy. A copy will be kept in my chart and a copy may be furnished to me at my request.