Financial Policy

Your Office Visit

To ensure our office provides quality care, please remember to always bring an updated list of medications, allergies, and previous surgical procedures. Also, please bring your current insurance card along with your copay, if applicable, to facilitate easy payment for your services.

Patient Forms

If you are visiting our office for the first time, or have not been seen within one year, you will need to complete quick and simple forms at or before your upcoming appointment. You may fill out or download all 3 forms located here on this page in the green patient forms box.

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Dr. Keeler

1880 Willamette Falls Dr Ste 111

West Linn, Oregon 97068

(503) 657-1900

Patients are responsible for all charges resulting from treatment provided by Dr. Keeler. As a courtesy to our patients we bill most insurance carriers directly. However, primary responsibility for the account is yours. Payment is due within 30 days from the point your insurance pays on your claim. Established patients with delinquent balance will be asked for payment at the time of service. All co-payments, coinsurance, deductibles and non-covered services are due at the time of service. Minors: The undersigned will agree to be responsible for payment of balances for services rendered to minors.

Payment Terms

I understand and agree that This Practice may use and disclose my health information in order to:

  • All new patients are required to pay for services in full, or insurance listed co-pays the day of the appointment. Please note: A new patient is defined as one who has not received professional services from Dr. Keeler., within the last 3 years.
  • A $5.00 handling fee is added to co-payments not paid at the time of service. It is your responsibility to make sure your co-payments are made.
  • If payment is not received from your insurance company within 60 days, we will require payment from you. Payments received from your insurance company after you have paid will promptly be refunded to you.
  • Checks returned for insufficient funds, closed account, or other problems are subject to a $30.00 service fee.
  • Accounts subject to collection activity may be charged a $30.00 Service fee.

Insurance Billing

Providing correct insurance billing information is the responsibility of the Patient. If your insurance changes, please present your new card. Notification of any changes of your primary care physician is also required. If complete billing information is not provided, the services will be billed directly to you. Medicare- we accept assignment on Medicare. If you have a secondary insurance, please provide that information so that we may bill for you. Worker’s Compensation- For us to file a worker’s compensation claims, we will need the name of your insurance carrier, date of your injury and your claim number.

Referrals

If your medical insurance requires a referral, it is your responsibility to obtain this prior to your appointment.

I have read and received a copy of the Payment Policy for Dr. Keeler. I accept this policy for my treatment.



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