James P. Borden, MD

Char Glenn, MD

Nob Hill Internal Medicine - Patient Contract

We are pleased that you have chosen a physician with Nob Hill Internal Medicine, P.C. as your Primary Health Care provider (PCP). Our goal is to provide the highest quality medical care. The following credit and payment policies have been established to assist in achieving this goal.

If you have insurance:  Please provide your insurance card(s) at the time of service. We will submit all claims to your insurance carrier(s) on your behalf through our billing agency MBA (503-283-5220). The contract for your insurance benefits is between you and your insurance carrier and questions or concerns about your insurance should be handled directly with the insurance carrier. Any balance remaining after payment from your insurance is due 10 days after receipt of your statement. Co-payments are due at the time of service along with payment for services not covered by your insurance. Our office can accept personal checks or cash, but cannot accept debit or credit cards.

If you are covered by Oregon Health Plan: You must be currently enrolled with the Oregon Health Plan and assigned to a Nob Hill physician to receive treatment. You must present your proof of coverage at the time of service.

If you are being seen for a work related injury: Please provide the registration desk with the name of your workers compensation insurance carrier, the date of your injury, the name and address of your employer at the time of injury, and your claim number (if you have one). Any questions about your coverage should be handled directly with your carrier. Nob Hill cannot be responsible for resolving any disputes about your claim.

If you are being seen for a motor vehicle or other third party liability claim: Please contact our billing agency, MBA, to work out a reasonable payment plan for the services that you receive from Nob Hill. We cannot postpone payment until the settlement of these claims and we cannot bill auto, homeowner and other personal insurance policies directly. We also cannot be responsible for resolving any disputes you may have regarding these claims.

If you do not have insurance: Please be prepared to pay for services rendered at the time of service. Our office will estimate your charges for you and bill you for any balance. If you have experienced an unexpected major medical event making payment at the time of service difficult, a payment plan can be arranged with MBA (503-283-5220).

Broken or cancelled appointments: Please notify our office 24 hours in advance to cancel or reschedule your appointment. You may leave a message with our answering service after hours or on weekends for unforeseen events. We reserve the right to assess a $25.00 cancellation fee for 15-minute appointments and $50.00 for 30-minute appointments that are cancelled or broken without required notice. If you are significantly late for your appointment please be aware that we may need to reschedule your appointment.

Terminating doctor/patient relationship: Nob Hill reserves the right to terminate its relationship with any patient. Usual causes for this include three "no shows" for scheduled appointments, abuse of narcotic medications, and inappropriate behavior towards doctors or staff. Fortunately, terminating a relationship is a rare occurrence.

Financial responsibility: The patient is financially responsible for services rendered. Nob Hill reserves the right to reschedule a patient if the patient is unable to make payments required at the time of service. A fee of $15.00 will be assessed for any checks returned for insufficient funds. Failure to meet financial responsibility may result in legal action.

Co-payment: Co-payments are due at the time you are seen. Our office accepts personal checks or cash. An ATM is located in front of the building facing Lovejoy. If you do not have your co-payment, you will not be seen.

Insurance Card: Please bring your insurance card with you to each visit.
 

I have read and understand the above policies for Nob Hill Internal Medicine. I accept this policy and agree to abide by the terms stated above.

 
 

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Page Last Modified   Feb. 17, 2001