New Patient Forms - English

Billing Information


The patient, parent or guardian accompanying the patient is responsible for providing our office with a valid and current insurance card. We must be notified of any changes, prior to rendering services. Patients unable to provide valid insurance information may be required to pay in full at the time of service or reschedule their appointment.

Copays, as directed by insurance, are due at the time of service unless prior arrangements have been made by our office. All missed co-pays will be assessed a $6.00 administrative fee. For you convenience, we accept cash, personal checks, VISA, and MasterCard. There is a $40.00 service charge for returned checks.

The bill will be sent to the health plan on record for direct payment to our office. If the insurance has not paid our claim within 60 days due to lack in information requested from the insured, we may expect payment from the patient. The patient, parent or guardian will remain responsible for any services that are not covered or noted as patient responsibility by the health plan.

All services deemed patient responsibility by insurance will be billed to the parent or guardian that has accepted financial responsibility. A statement will be generated by our office and all balances are due and payable in full unless other arrangements have been made with our billing department.


Accounts with outstanding balances that are 60 days overdue will be required to contact our billing department to make payment arrangements prior to scheduling appointments. As a courtesy, budget payment arrangements can be made until the balance is paid in full. Budget payments are due each month. Missed payments may result in a default of your budget payment arrangements and may result in your account being assigned to a credit reporting collection service.

Please note that payment collected at the time of service may not reflect the full patient responsibility after insurance. Our office is not responsible for any limitations in coverage that may be included in your plan. We advise our families to understand their insurance benefits and review their explanation of benefits and billing statements carefully. If you feel there has been an error, always contact the appropriate party with questions within a timely manner.


Under Washington State law, minors have the right to consent to certain health care without a parent or guardian’s consent. For further information, please look under our New Patient Information section for the “To the Parent of Minor Children” form.

Once a patient becomes pregnant, their care will be transferred to an appropriate provider who cares for pregnant patients.

Financial Policy (Spanish)