Consultation with Dr. Lisa Del Alba

Financial Policy

We are doing everything possible to hold down the cost of patient care. You can help a great deal by eliminating the need for us to bill you. The following is a summary of our payment policy.

PAYMENT IN FULL IS EXPECTED AT THE TIME OF SERVICE

Unless your practitioner is a preferred provider on your insurance plan

Forget Me Not Medicine accepts cash, personal check (in-state only), VISA, MasterCard, Discover, and American Express. There is a $25 service charge for returned checks. To be in compliance with the new FTC Red Flag Rules and to further protect your credit from Identity Theft, we now require a photo ID for bank card and check payments and at your first visit to verify your identity.

INSURANCE: We bill your primary insurance company as a courtesy to you. You are expected to pay in full at the time of service. As a service to you, our customers, we will submit an insurance claim to your primary insurance company with the reimbursement to come directly to you. You are responsible for filing with your secondary insurance company after receiving notice from your primary about what is covered.

At the time of service, you will receive a receipt that includes all the information necessary for submitting claims to your insurance company for yourself.

If you need assistance or have questions, please contact the front office at (541) 799-6097 will be changed to 360-630-7863 on March 9, 2024. Appointments are available for detailed financial consultation when necessary.

EXCEPTION: If you receive services from a practitioner who is the preferred provider on your insurance plan, we will accept your co-pay and bill your primary insurance the balance. You are still responsible for billing your secondary insurance.

REFUNDS: Overpayments will be refunded upon written request within 30 days.

MISSED APPOINTMENTS/LATE CANCELLATIONS: Broken appointments represent a cost to us, to you, and to other patients who could have been seen in the time set aside for you. Cancellations are requested 24 hours prior to the appointment. We reserve the right to charge for missed or late-canceled appointments. Appointments that are rescheduled within 5 business days will not be charged. Excessive abuse of scheduled appointments may result in discharge from the practice.

PAST DUE PAYMENTS: Any past due payment will be charged a 1.5% late fee per month or partial month. Accounts more than 90 days past due will be sent to collections.

I have read and understand the Forget Me Not Medicine Financial Policy. I agree that if it becomes necessary to forward my account to a collection agency, in addition to the amount owed, I will also be responsible for the fee charged by the collection agency for costs of collections.