Demographic information (FFS)
CONSENT TO BE TREATED
I give permission and authorize the providers and staff of Greenlake Primary Care to examine and treat me. If treatment is for a minor, I hereby give permission for the patient to receive treatment. In the rare even that I cannot be reached, I authorize GPC to institute any necessary care for the patient, including hospitalization. This authorization is in effect until rescinded in writing.
Greenlake Primary Care Financial Policy (updated 1/2021)
Greenlake Primary Care currently (Jan 2021) participates with a wide variety of insurance plans including: Aetna, First Choice, Labor & Industry, Medicare, Premera, Regence, Uniform, and others. We do not bill third party for motor vehicle accidents. We do not take EPO plans or HMO plans. We no longer contract with Tricare, or United Healthcare. If you do not have insurance, or if we are out of network for your insurance, you may qualify for Direct Primary Care membership. (After May 2021 – we will no longer contract with any private insurance, nor will we submit bills on your behalf. )
Know your insurance plan. Before your visit, call the toll free number on the back of your insurance card. Make sure you know if we are assigned as your primary care provider.
Until April 30, 2021, Greenlake Primary Care will submit your bill to your insurance company for you. We will continue to bill for Medicare. If we are out of network, you are responsible for paying at the time of service and we will submit your bill to your insurance company on your behalf as a courtesy. We make no guarantee regarding insurance reimbursement or payments.
If you do not have medical insurance, it is your responsibility to make full payment at the time of your visit for the services given. If there is financial hardship, please let us know and ask about our Direct Primary Care membership program.
Questions about your account can be answered by Physician Billing Partners at (206) 932-9025
I have read and understand this policy. A copy will be kept in my chart and may be furnished to me at my request. All authorizations are in until rescinded in writing
Credit Card and/or ACH withdrawl Authorization:I authorize Greenlake Primary Care to charge my credit card or ACH account on file for all charges as well as any co-pays, or balances that are due. 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 will be stored in my chart or in the office and the card number or bank account information cannot be accessed once entered.
BILLING INFORMATIONINSURANCE INFORMATION
If you are not the primary insured please fill in the following information. For minor children the Parent with the first birth month (i.e. January vs February) will be considered “primary insurance” holder for all doubly covered children.
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENTGREENLAKE PRIMARY CARE We want to inform you of the rights you have as a patient under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), as updated by the 2013 HIPAA Final Omnibus Rule. In summary under HIPAA, I understand that my personal information may be used to: · Provide and coordinate my treatment among a number of healthcare providers who may be involved in my treatment directly or indirectly· Obtain payment from third-party payers for my healthcare services· Conduct normal healthcare operations such as quality assessment and improvement activities I have been informed of Greenlake Primary Care’s (GPC) Notice of Privacy Practices and understand that I may request a copy of this Notice for my own use. I understand that GPC have the right to change their Notice of Privacy Practices and that I may contact this office to obtain a current copy. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I further understand that GPC are not required to accept my requested restrictions, but if they are accepted then I understand that they will honor my request unless it is an emergency. I further understand that I have the right to not sign this acknowledgement and may still receive treatment at GPC. Our Notice of Privacy Practices describes in more detail how your health care record may be used and disclosed, and how you can access your information. Copies are available at our office or on our website: www.greenlakeprimarycare.com. I acknowledge that I have had the opportunity to review the Notice of Privacy Practices. This signed acknowledgement will be retained in my medical record, in accordance with HIPAA Privacy Act regulations.