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

Financial Agreement


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

Check-In Policy

New patients and established patients with any changes to your insurance or demographics need to check-in 15 minutes prior to your appointment time to allow the receptionist enough time to process your information.

Appointment No Show Policy

In order to provide the best care and service to our patients, we ask that you notify us at least one day prior to canceling or rescheduling your appointment.  Patients who fail to appear for their appointment without notifying the office may be subject to a $25.00 No-Show charge. This fee will be charged directly to the patient and not to the patient’s insurance. Patients who fail to show for their appointment more than 3 times may also be subject to dismissal from the clinic. Patients may contact the Clinic Administrator at (509) 332-6139 to request a waiver if there is an extenuating circumstance.

Late for Appointment Policy

If the patient is not available at the scheduled time, the appointment time may be given to the next scheduled patient.  The originally scheduled patient can either reschedule or wait for the next available appointment time, which may or may not become available that day. Patients who are late for their appointments more than 3 times will not be allowed to schedule without prior approval from the attending physician, and may also be subject to dismissal from the clinic.


You have entrusted us with one of your most valuable assets, your health. We strive to provide quality care in accordance with your wishes; we are dedicated to protecting your dignity at all times. There are also certain responsibilities that you must assume as a patient. We will provide a copy of these Rights and Responsibilities upon your first visit to our office. They are also posted on our website: you have any questions regarding these rights and responsibilities, please let your provider know and we will be happy to discuss them.


We recommend you visit our website and register on our portal. You can request appointments, medical records, update patient information, refill prescriptions and pay your bill on-line at


To provide the best care possible, PRH Clinic Network, LLC and its affiliates seeks to communicate with our patients in a convenient and effective manner, including e-mail, text or other electronic means if requested by the patient and deemed appropriate by PRH Clinic Network, LLC and its affiliates. Please note that such communications sent through the internet or over phone systems may not be encrypted or secure, and could result in unauthorized persons accessing your information.  If you would like PRH Clinic Network, LLC and its affiliates to communicate with you electronically despite these concerns, please indicate your preferred method of communication and sign below.

Preferred Method:

Based on your preferred method of contact choice above, please provide the information for the method you chose.

Email: Use this e-mail address:
Text: Use this text number:
Detailed Phone Voice Message: Use this phone number:
Other Means: (subject to PRH Clinic Network, LLC’s approval):

Notice of Civil Rights Nondiscrimination Statement and Accessibility Requirements:

Pullman Regional Hospital Clinic Network, LLC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.  PRHCN, LLC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

            Pullman Regional Hospital Clinic Network:

  • Upon request, provides free aids and services to people with disabilities to communicate effectively with us, such as:

                        ○ Qualified sign language interpreters

                        PRHCN uses CTS Language Link, 1-855-295-9177

            ○ Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:

                        ○ Qualified interpreters

                        PRHCN uses Telelanguage 1-800-514-9237

                        ○ Information written in other languages

            If you need these services, contact the Clinic Administrator or Manager at the office and notify them of your need.

If you believe that Palouse Pediatrics has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Clinic Administrator or Manager, SE 1205 Professional Mall Blvd. Ste 104 Pullman, WA. 99163, 509-332-2605, 509-334-5754, [email protected] You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Clinic Administrator or Manager is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at, or by mail or phone at:

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at

Language assistance available: Español | 繁體中文 |Tiếng Việt | 한국어 | Русский | Tagalog | Українська | ខ្មែរ | 日本語 | አማርኛ  | العربية | ਪੰਜਾਬੀ | Deutsch | ພາສາລາວ | Srpsko-hrvatski | नेपाली | Français | Română | فارسی

Patient Financial Agreement & Release of Information

During your visit:

  • Copays are due at time of check-in as outlined in the provisions of your insurance policy.
  • Account balances are due upon check-in/check-out. In the event this is not possible, you will need to set up a payment plan with our central billing office by calling (509) 332-6139.
  • For out of network plans or high deductibles you may be asked for a deposit towards treatment or pay your insurance’s allowable rate at the time of service.
  • All insurance plans have exclusions to their policy. We advise you to review your insurance plan’s exclusions prior to your visit.

Private Pay/ No Insurance:

  • Payment is due at the time of service.
  • Most services are eligible for a 20% discount for payment in full at the time of service. Please contact our central billing department at (509) 332-6139 with any questions.

      I read and understand the information above, it is true and correct to the best of my knowledge. If bills remain unpaid without previous payment arrangements, PRH Clinic Network, LLC may initiate collection procedures and/or legal actions, which will necessitate the release of confidential information for dates and types of services rendered. I agree to reimburse PRH Clinic Network, LLC the fees of any collection agency, which may be based on a percentage at the maximum of 40% of the debt, and all costs, and expenses, including reasonable attorneys’ fees, we incur in such collection effort. I hereby release PRH Clinic Network, LLC from all liability arising therefrom.

      I understand that I am financially responsible for all charges whether or not paid by my insurance company. I, the undersigned, authorize treatment and request payment of authorized Medicare & Medicaid services and/or other insurance benefits be made payable on my behalf to PRH Clinic Network, LLC, for any services furnished to me or my dependents by PRH Clinic Network, LLC or its affiliates. I authorize the holder of medical information about my dependents or me to release to the Centers for Medicare & Medicaid Services (CMS), its agents, and/or my current insurance company or any subsequent insurance companies from which I obtain coverage, any information needed to determine these benefits or the benefits payable for related services. If “other health insurance” is indicated, my signature authorizes release of the information to the insurer or agency shown.

Patient’s Name:
Signature: (Patient, Parent, Guardian, or legally authorized individual signature)
Printed name if signed on behalf of the patient
Relationship to Patient: