Credit Policy

It is the concern of our entire staff that financial matters do not become a burden, nor stand in the way of your receiving the best, most timely medical attention. It is for this purpose that we have formulated the following Credit Policy:

1. If you have insurance coverage, we will gladly file your insurance claim for you. We do request payment of any co-payment or deductible at the time the services are rendered. If you do not have insurance coverage, we request that you pay for all services when rendered. If you are unsure of your copayment amount, we will collect a standard $25 copay at the time of service.

If you are separated or divorced, the parent bringing the child in for treatment is responsible for payment at the time of service. Whatever financial agreement exists between you and your spouse is strictly your agreement and not part of our credit policy.
2. We currently are member physicians with Montana Health Coop, United Health Care, Allegiance/Cigna, Blue Cross/Blue Shield of Montana, Pacific Source, First Health Network, Interwest Network, Multi-Plan Network, Medicare and Medicaid of Montana. However, we remind you that your insurance policy is a contract between you and your insurance company and does not affect our credit policy.

This practice is committed to providing the best medical treatment possible for our patients and charges what is usual and customary for our area. You are responsible for payment in full regardless of your insurance company's determination of usual and customary allowances.

3. Accounts that accumulate a balance over $750.00 without regular payments within 90 days, will be required to sign a payment agreement with stored credit card information for automatic monthly payments of 10% of the patient balance. Guarantors of accounts will be contacted directly via letter and a call by an office administrator.

4. Should circumstances arise where your account still has a balance one year from the date of service, we ask that you seek alternative financial options and pay your account in full. Accounts that become greater than 90 days delinquent, with no attempt by the responsible party to make arrangements for payment, will be turned over to an independent collection agency.

5. Accounts returned to us as "undeliverable", i.e., moved without forwarding address, etc., will be held for one month, and if no contact is made, will be turned over to an independent collection agency.

6. In the event that an account must be turned over to a collection agency, we will request that you and your family seek medical care from another physician in the community. Failing to fulfill your payment obligation injures the mutual respect of the patient-doctor relationship set forth to ensure the highest quality of medical care; thus, we must insist the relationship be terminated. You understand that should you default on payment of your account and collection agency services are required, all costs of collections up to 40% of the balance, including attorney/court costs will be added to the balance of your account.

The biggest single misunderstanding and possible source of problems for you and for us occurs when there is no communication about your financial matters. Please feel free to discuss fees and financial arrangements with us at any time. We are more than happy to work with you so that there is never a time that your medical care causes a financial burden. We will do our best to ensure that we fulfill our part of this agreement with you, and trust that you will do the same.

Patient Signature Renewal Form:

In compliance with HIPAA regulations, BCFH is required to have patient signatures on file once a year.

I, attest that all demographic information is correct and current to my knowledge. I have read the credit policy and agree with the terms. I have read the privacy policy and agree with the terms. I have provided BCFH with my current insurance information.

May we leave clinical messages on your phone?

Current Demographic Information:

* You will receive appointment reminder calls OR text messages on the primary number listed. If the secondary # that is listed DOES NOT BELONG TO PATIENT, Please clarify who the number belongs to.

Authorization to Disclose Health Information

As a patient of Bozeman Creek Family Health, you are protected under The Health Insurance Portability and Accountability Act of 1996 (HIPAA). We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

I authorize to inquire about:

Please check all that apply:

No Show and Cancellation Policy for Medical Appointments


As a patient in our clinic, it is your responsibility to keep scheduled appointments. Bozeman Creek Family Health requires notification of cancellation at least 24 hours prior to the scheduled appointment time. BCFH will consider it a “failed appointment” any time a patient has not given the advanced notice required above or fails to arrive within 10 minutes of their scheduled appointment time. If a patient has 3 failed appointments in a one year period, BCFH will no longer schedule appointments for that patient.

No Show:

If a patient fails to arrive at the scheduled appointment time and does not call to cancel the appointment, the patient will receive a letter in regards to the missed appointment. If a patient has 2 “no show” appointments in a one year period, BCFH will no longer schedule appointments for that patient. All patients will be charged a $75.00 fee for every failed appointment or no show.

If you feel there has been an error in scheduling or believe you deserve special consideration, please let us know and you may speak with our Office Manager.


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