Whole Health ClinicDr. Sharum Sharif

6632 S. 191st Place,Suite E-110 Kent, Washington 98032 (425) 656-0700

New Patient Information & Policies

FEES FOR CASH PATIENTS:

First time office visits cantake up to 45 minutesand the fee is $175.

Future or return visits can take up to 30 minutes, and the fee is $95.

Future or return visits 15 minutes or less: $65

Fee for the finger prick part of the US Biotek’s food allergy testing: $20

Note: Often Dr. Sharif offers a homeopathic remedy to his patients during the visit. The charge for this remedy is $15 which is not reimbursable by insurance companies.

INSURANCE: Our doctors arecurrently contracted primary care providers(PCPs) for United Healthcare, Uniform Medical, Cigna,Alternare (Premera, Lifewise, etc.), First Choice, and American Whole Health (Aetna). We are out of network with Group Health Cooperative. However, many of our Group Health patients have out of network coverage which covers our services. They are considered a “specialist” (versus a PCP) for patients who have Regence insurance, and therefore, some Regence patients (depending on their particular plan) might need a referral from their PCP in order to see either doctor. Other Regence patients can see either doctor without a referral from their PCP. If your insurance carrier is any of the above, you will just pay a co-pay at the time of service. If your insurance carrier is not contracted with the doctors, then you will be expected to pay our office fees in cash. We canprovide a super bill for you at time of service which you cansubmit to your insurance company to request reimbursement. Most insurance providers will reimburse a substantial amount of the visit. You can call your insurance company and ask them the extent of their “out-of-network coverage” for first office calls, return visits, as well as laboratory fees.

DISPENSARY ITEMS:

We have a dispensary at our office, and many of the supplements/remedies that are prescribed to you can be obtained from this dispensary. Unfortunately, at this point in time,

Natural medicines (“supplements”) are NOT covered by insurance companies, and you are expected to pay for them yourself. Note that we do not accept returned medicines/supplements. Keep in mind that many of the medicines that we prescribe are not available over-the-counter and can not be obtained at a regular pharmacy. We do NOT charge tax on our supplements for our current patients.

PAYMENT: PAYMENT IS DUE AT THE TIME OF SERVICE. A payment plan for return office visits can be determined on an individual basis at our discretion. We accept cash, check or credit cards.

CANCELLATION: We dedicate 30-60 minutes per visit specifically for you. We appreciate your thoughtful efforts to give us advanced notice (of at least 48 hours) if you were to cancel your appointment.

Note: Due to the chemical sensitivity of a number of our patients, please refrain from wearing perfumes or scented body products when you come to our office.

I (printed name) ______AGREE TO THE CLINIC POLICIES STATED ABOVE.

______

YOUR SIGNATURE DATE