Palouse Pediatrics

Palouse Pediatrics, Pullman
1205 S.E. Professional Mall Blvd. Suite 104
Pullman, WA 99163 (map)
Phone: 509-332-2605
Fax: 509-334-5754

Palouse Pediatrics, Moscow
1420 S. Blaine St, Suite 5
Moscow, Idaho 83843 (map)
(Located in Eastside Market Place)
Phone: 208-882-2247
Fax: 208-882-2292

Circumcision Payment Policy and Financial Agreement

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Fill-out the form below and then print it out. Your information will not be saved or sent.

Routine circumcision is an elective surgical procedure, therefore as a parent you must decide if you want this procedure for your child.

Many insurance companies including Idaho and Washington Medicaid will not reimburse for routine circumcision. Insurance companies that do cover this procedure will often apply the circumcision cost to the patient’s surgical deductible.

Total cost for a circumcision is $300

Before your child’s circumcision, our office will contact your insurance company for benefits and any prior authorization requirements.  We recommend you do the same. It is important you are aware and understand your child’s medical benefits and what dollar amount will be your responsibility. The final cost to you is determined by how your insurance company pays for the procedure. If insurance pays for any portion of the circumcision procedure the 20% discount does not apply.  Please be aware, benefits given by your insurance company are not a guarantee of payment.

By signing below you understand that the circumcision is an elective surgical procedure and the cost is $300.00.

Parent’s Signature:
Date:
Print Parent’s name:
Witness Signature (employee):
Patient’s name:
Patient’s DOB:
Phone Number:
-
Date circumcision is scheduled:
with Dr.
Insurance Plan:
Insurance Policy Holder’s Name:
DOB:
Insurance Identification Number:
Group #:
Date verified:
Reference Number:
Name of Representative:
Covered benefit? :
Deductible met?
Patient’s deductible: $
How much of deductible has been met? $
Amount to collect: $
Date Parent Notified:
Staff Initials & Date:
Staff Notes: