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1.Medical History Intake Form. (Once completed, our Staff will then contact you to schedule an appointment. A credit card number will be required at the time of scheduling to reserve your appointment time.) 2.Information regarding Costs, Payment Policy, and Insurance information.3.Client Provider AgreementPlease mail the following to the office prior to your scheduled appointment, if applicable:1.Most recent Mammogram 2.Most recent Pap smear.3.Most recent Bone Density Scan 4.All blood work completed within the last year 5.Any other information pertinent to your situation.Thank you for your cooperation and I look forward to meeting with you soon.Sincerely,Lynn A. Chadd, MSN, ARNP, PS
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• New Patient Consult appointment cost is $317.00.
Your first follow-up appointment is included in this price.
• Face-to-face appointments can be scheduled at the Peshastin, Washington office or at the Poulsbo Compounding Pharmacy.
• Telephone appointments are also available for our distance patients; cost is the same as an in office appointment.
•Saliva Hormone Testing is $175.00 --- Saliva Testing is required while being treated with bio-identical hormones. On average, saliva testing is completed when treatment is initiated, when prescriptions are adjusted and yearly when treatment has stabilized. Frequency of saliva testing will vary from person to person, depending on response to treatment.
• Cost for New Patient Consultations and Saliva Hormone Tests are subject to change. Please confirm current fee schedule at time of scheduling appointment.
• Payment is due at the Time of Service, as insurance billing services are not provided.
We accept Master Card, Visa, Checks, or Cash.
• Appointments will be reserved with a credit card or check. Please submit checks in advance of telephone appointments.
• For appointment cancellations, 48 hour notice is appreciated. Failing to show will result in a $125.00 charge.
• Refunds for supplements and/or test kit purchases will be provided for up to 90 days after the purchase date. Restrictions may apply.
• At the time that services are paid, an itemized statement will be provided. This will include all necessary insurance codes and information for self billing. Please consult with individual insurance plans for correct self billing instructions and appropriate forms. It is advised to make copies of all forms prior to submitting insurance claims.
• Please be informed that Lynn is an Out of Network Provider/Non-Preferred Provider and is not contracted with any insurance companies.
• Medicare does not permit patients to self bill.
• I understand that Lynn Chadd, MSN, ARNP, PS does not accept insurance as payment and that I am responsible for payment at the time of service. I have read and agree with the cancellation policy.
• I understand that if Medicare is my insurance—I cannot self bill Medicare for reimbursement as per Medicare’s billing policy and that I am agreeing to pay “out of pocket” for all services—at the time of service.
• I understand that the main focus of Lynn Chadd’s practice is preventative healthcare, integrative care of chronic problems, and treating hormone imbalance in men and women. I understand that Lynn Chadd does not provide after hour, urgent, emergency or on call care. I have been advised to retain or maintain a Primary Care Provider for my other health care needs. I have been advised that in the event of an emergency I should dial 911 or go to my local emergency department.
• I have provided accurate medical history information on the Medical History Intake Form.
• I understand that all of my records and information will be confidential according to “The Healthcare Privacy Act”.
Please list any phone numbers where you would like to be contacted and/or messages left:
Please include an E-mail address for receiving messages, results and reminders
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