Patient Forms
You may download and print any of the forms listed below before coming to our office. You may either bring them with you to your visit or fax them to us before your appointment. To view our forms, you will need Adobe Reader. You may download Adobe Reader for free by visiting www.adobe.com.
- Patient Registration Form [pdf]
- Release of Records (incoming) [pdf]
- Release of Records (outgoing) [pdf]
- HIPPA Exhibit A - Chart Review Request [pdf]
- HIPPA Exhibit B - Medical Information Request [pdf]
- HIPPA Exhibit C - List of Non-Routine Disclosure Form [pdf]
- HIPPA Exhibit D - Complaint Form [pdf]
Practice Policies
Credit Policy, Fees, and Insurance
Many of the services provided by our office are covered and paid by your insurance company. We willingly file the claims for you so that you do not have the additional concern and effort of dealing with this. However, all professional services are rendered to the patient and not the insurance company. As such, all charges, regardless of insurance coverage are the patient’s responsibility. We do expect payment for your portion at the time of service. (co-pays, co-insurance, deductibles). We ask that if your insurance has not paid within 45 days that you follow up with them. Our office currently contracts with the following insurance companies:
- Altius
- Blue Cross of Idaho (except Chamber Blue)
- EDS/Medicaid
- First Health
- Regence Blue Shield of Idaho
- St. Luke’s Employee Health Plans
- Tricare (certain physicians only)
**Contact our Business Office at 208.345.2055 or your insurance company for in-network details.
Recent Federal laws addressing all insurance companies require that we submit every claim to an insurance company accurately, reporting the exact services performed and the exact reason for performing them. We are not allowed to change this information just so the insurance company will pay the claim. Our practice is committed to these new laws and will submit all claims to all insurance companies in this manner.
During your child’s well check-ups, we will update all of his/her known conditions as well as look for any new problems. Unless there is some major new finding during this examination, we must submit the service to your insurance company as a well child exam, which may or may not be covered by your insurance company. In addition, if during this examination a significant new medical problem should present itself, an additional service may be billed.
We realize that often medical expenses are not anticipated, and we are willing to work with you in advance to make financial arrangements. In order to do so, we must know that there is a need for an exception to our policy. If you have any questions or concerns, please ask. Our billing office staff can be reached directly at 345-2055.