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Call (360) 794-1415

Surgical & Vein Care Information and Forms

We thank you for choosing EvergreenHealth Surgical and Vein Care. Below are your registration forms and answers to frequently asked questions about your visit.

Registration Forms

For your convenience, registration forms can be downloaded and completed prior to your appointment.

Patient Registration

Health and History

Consent for Care

Patient Bill of Rights

Financial Agreement

Individuals Involved in Care

Literacy Screening

Co-Pays and Insurance

We are contracted with most insurance plans. We require your insurance card and a photo ID the day of your appointment so we can bill your insurance correctly. Any co-pays required by your insurance plan are collected at the time of your visit.

Non-Insured Patient

If you are paying for your own healthcare, $75 is required at the time of your visit. If surgery is required we require half down prior to the surgery. Our surgery scheduler will go over payment arrangements.


For non-emergent care, your insurance company may require a referral. As a patient obligation we ask you to either send that to us prior to your appointment or bring it with you to your appointment. If we do not receive your referral, your insurance company will decline to pay your full benefit.

Financial Policy

The following information will answer your questions about our financial policy. Should you need further assistance, please contact our office at 360.794.1415.

Participating Health Insurance Plans

We are contracted with most major health Insurance plans. We ask that you contact your insurance carrier (there should be a customer service number on your insurance card) to inquire if Michael S. Eickerman is a participating provider. You may also contact our office.

Insurance Processing

As a courtesy, we will process and file your insurance claims. You are responsible for any co-pays and all balances not covered by insurance. It is your responsibility to understand and comply with any predetermination of benefits or referral requirements.


If your health plan requires a referral, it is your responsibility to make sure an appropriate referral has been requested prior to your visit. Typically, your primary care provider will begin this process if they are the referring physician. Some health plans require a referral for each visit, others do not. If you do not obtain a valid referral from your primary care physician, and your health plan does not pay for our services, you will be responsible for payment.


If your insurance requires a co-pay, this will be paid at your appointment. This fee is not covered by your insurance.

Medical Services for the Non-Insured

If you do not have insurance coverage, you will be asked to pay for your visit at the time of service.

Non-Covered Medical Services

For services not covered by insurance, the we require full payment of the total charges prior to treatment.

Past Due Accounts

Overdue accounts will be referred to a collection agency, and any legal fees paid to secure past due balances will be applied to your account. We do realize that temporary problems may affect timely payment of your account. If such a problem arises, please let us know so we can assist you in arranging monthly payments over an approved term.