ACKNOWLEDGEMENT OF POLICIES AND PRIVACY PRACTICES
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.
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.
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.
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.
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.
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.
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.
I understand that co-insurance amounts may be collected at time of service, and when procedures are scheduled.
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
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.
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.
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.
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.
Consent to Treat
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