Please read and sign the following informed consent agreement:
Your visit includes a private examination with a licensed physician. Your doctor will talk to you about your medical condition and perform any physical examples or lab tests medically indicated and agreed upon by you for the chief concern that brought you to the clinic.
**PLEASE READ CAREFULLY AND SIGN AFTER READING**
We at Femme Clinique are here to help you to take care of your health in the best way that we know how. We realize you came in about health and not finances. The following is to assist you in understanding Femme Clinique financial policies:
Appointments must be paid for at time of service unless otherwise agreed. We accept VISA, MasterCard, Discover, American Express, Cash, and Check. You will be charged a $25 fee for a returned check.
We require 24 hours in advance of notice if you need to reschedule or cancel our appointment. You will be charged a $50 No Show fee for a missed appointment.
We keep a record of your health care. Please allow up to 10 business days for us to process a medical record request. A processing fee will be charged for this service if requested by a third medical records requesting company. We will not disclose your records to others unless you direct us to do so or unless it is required by the law.
Insurance and Fee
Femme Clinique is contracted with Premera and Regence currently. Cash discount is available for patients who don’t have Premera and Regence as their medical insurance. We are entitled to bill the patient for charges that their insurance does not cover. Please understand that the patient is responsible financially for their visit to Femme Clinique.