• INFORMATION CONSENT
  • Our office sees patients by appointment only. Please be on time as late arrivals will forfeit their appointment if 15 minutes late. New patients are expected to arrive 15-30 minutes early for their initial visit. If you need to cancel or reschedule your appointment, you are required to give a 24 hour notice to avoid being charged for the visit. Every effort will be made to see everyone in a timely manner.
  • All patients will be expected to bring in for EVERY VISIT; Valid Insurance card and a Valid Photo I.D. Also, all co-pays, co-insurance, deductible and non-covered service payments at time of service. If you do not have these at time of service, your appointment may be re-scheduled for another date and time.
  • Be aware that if narcotic medications are prescribed to you from this clinic, this clinic should be the only office that writes for narcotic medications. Take this medication as directed. If you receive other narcotic prescriptions from another institution, it is your responsibility to inform this office. Taking extra medication can cause you to become overly sedated and is dangerous. It will also cause you to run short or out of medication before your refill or next appointment.
  • If you feel that the medication or treatment is not controlling your condition, you will need to schedule an appointment to discuss this concern. We ask that you do not destroy or throw away any narcotic medications. Return policy on narcotics is that you must bring any unused medication as we count the old medication before issuing a new narcotic prescription.
  • No early refills will be provided. No lost or stolen prescriptions will be replaced for any reason. If your medication is stolen and there is a police report, we are still not responsible and will not replace medications or prescriptions. We ask that each individual be responsible and lock their medications in a safe place.
  • Medication refills will not be provided over the phone. Written prescriptions will not be allowed to be picked up at the front desk. All prescriptions require a scheduled appointment.
  • We ask that you try to use one pharmacy when possible and keep staff informed of any changes at each visit.
  • For any emergent needs, report to your nearest emergency department for immediate medical attention.
  •  Photo ID and Insurance Card must be presented at EVERY VISIT or your appointment may be rescheduled due to anti-fraud legislation. 


ACKNOWLEDGEMENT OF POLICIES AND PRIVACY PRACTICES

  • INSURANCE AUTHORIZATION

I hereby authorize Sleep Apnea Solutions, LLC, Stanford Feinberg M.D., P.C., Eastern Pennsylvania Sleep Disorder Center to share information with hospitals and physicians, my insurance carriers, worker’s compensation companies, attorneys, etc. concerning my illness and treatment.

  • ASSIGNMENT OF BENEFITS

I hereby assign to Sleep Apnea Solutions, LLC, Stanford Feinberg M.D., P.C., and Eastern Pennsylvania Sleep Disorder Center all payments for medical services rendered to my dependents or myself. I understand that I am responsible for any amount not covered by insurance.

  • TREATMENT AUTHORIZATION

I hereby authorize Sleep Apnea Solutions, LLC, Stanford Feinberg M.D., P.C., Eastern Pennsylvania Sleep Disorder Center to render health care to me during my visit.

  • PRIVACY NOTICE

 I have been given the option to review Sleep Apnea Solutions, LLC, Stanford Feinberg M.D., P.C., Eastern Pennsylvania Sleep Disorder Center “Notice of Privacy Practices” that explains how my personal health information will be used. I am also aware that I may request a copy of the “Notice of Privacy Practices” at any time.


FINANCIAL POLICY

  • INSURANCE BENEFITS

Pennsylvania law requires that medical claims be paid by the insurance carrier within 30 days. As a courtesy, we will bill your insurance for all covered services. If your insurance carrier has not appropriately paid the submitted claim within 30 days, all outstanding balances will become patient responsibility.


  • INSURANCE CO-PAYMENTS

In accordance with my insurance contract, I understand that co-payments are due at the time of service. This contractual obligation requires that the co-payment be made at time of service, so it may be necessary to reschedule your appointment if co-payment is not made.


  • DEDUCTIBLE

If my insurance deductible has not been met, I understand that full payment, up to total deductible amount, will be collected at the time of service.

  • CO-INSURANCE

I understand that co-insurance amounts may be collected at time of service, and when procedures are scheduled.

  • PRIVATE PAY

If I have no insurance coverage, or insurance with which Sleep Apnea Solutions, LLC, Stanford Feinberg M.D., P.C., Eastern Pennsylvania Sleep Disorder Center does not participate, full payment is expected at time of service and our practices retains the right to cease services or refuse patient care if patient does not have coverage with an in-network provider

  • SECONDARY INSURANCE

I understand Sleep Apnea Solutions, LLC, Stanford Feinberg M.D., P.C., Eastern Pennsylvania Sleep Disorder Center will file claims with secondary insurance carriers and that I am fully responsible for secondary insurance amounts after 30 days.


  • VERIFICATION OF BENEFITS AND NON-COVERED SERVICES

Insurance policies may differ per patient plan. Sleep Apnea Solutions, LLC, Stanford Feinberg M.D., P.C., Eastern Pennsylvania Sleep Disorder Center may provide services that my insurance plan excludes. It is my responsibility to verify and understand my coverage benefits and exclusions. All non-covered services are my responsibility and are due at time of service.
I understand it is my responsibility to know and obtain a Referral Form from my PCP prior to my appointment if deemed necessary by my insurance coverage.


  • COLLECTIONS

If my account is placed into collections, I will be responsible for all collection costs equal to 30% of my outstanding balance, but no less than $25.00. 

  • NO SHOW/LATE CANCELLATIONS/RETURNED CHECKS

Office visit cancellations made less than 24 hours in advance or if you “No Show” will be subject to a $45.00 fee. Procedure cancellations made less than 72 hours in advance or “No Show” will be subject to a $250.00 fee. Three “No Show” visits in a row and/or frequently rescheduling your appointments will result in a discharge from the practice. These charges are my responsibility and will not be billed to my insurance carrier.  Returned checks will be subject to a $25.00 returned check fee, and all future payments must be paid in cash.

Thank you for understanding our financial policy.  Please let us know if you have any questions or concerns.


Call Us:   610-378-5566

Consent to Treat

Please read these forms in their entirety and virtually sign the box below. This form must be signed in order for us to see you as a patient.