NEW PATIENT INFO

FINANCIAL POLICY

This form is to inform you of our billing practices and financial policy.

Insurance and Billing.

To verify if we accept your insurance, please contact our office. If we do not accept your insurance, we may be able to issue a letter of medical necessity for you to use to request for reimbursement from your insurance company. Payments you are responsible for are due prior to your visit/testing.

Payment Options.

Payment options accepted include cash and credit cards. Please ask our staff about all payment options.

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FORMS AND FEES

There is a charge for all forms. Please allow up to 7 business days for completion of forms. All forms must be left at the front desk even if you bring them on the day of your appointment. Expedited processing of forms will be considered on a case-by-case basis and additional fees may apply. Payments must be made at the time forms are released. Please speak to our staff for details about forms and applicable fees.

Forms/letters: $100 each

Medical Opinion letters: $250 each

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CANCELLATION POLICY

If for any reason you must cancel or reschedule your medical appointment, you must give us 24 hours’ notice to avoid a $50 no-show or late cancelation fee. This fee is not billable to your insurance and is your responsibility. If you arrive more than 15 minutes late to your appointment, the appointment may be canceled or rescheduled. If you arrive late but less than 15 minutes late to your appointment, you may be asked to wait until the provider has an opening for you to be seen. For in-lab sleep study appointments, you must provide a minimum of 3 business days cancellation notice to avoid a $150 no-show or late cancelation fee. This fee is not billable to your insurance and is your responsibility.

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If you have any questions regarding these policies, please speak to our staff and we would be happy to assist you.

I hereby authorize my insurance benefits to be paid directly to the physician and/or physician group for which I am financially responsible for all charges. I also consent to the release and re-disclosure of my medical record to enable or facilitate the payment, collection, verification, or settlement of my account for any amounts due from me or any third-party payor, health maintenance organization, insurer or other health benefit plan.

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Our office will obtain a general breakdown of your insurance benefits from your insurance carrier. This information can be provided to you upon request. This information is not a guarantee of benefits; we highly recommend that you contact your insurance carrier to get more specific approval for all services.

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If at any point you change insurance, or your insurance policy terminates or cancels coverage, you will be fully responsible for all charges that are not subject to being refiled with any new insurance provided. Most insurance(s) have timely filing requirements and if they are not met, we are not able to rebill those services. It is imperative that you notify our office immediately of any changes to your policy. If we are unable to refile your claims, you will be fully responsible for all charges. This includes any SECONDARY insurance related information as well.

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REFERRAL POLICY

I understand that if my insurance carrier requires a written “Insurance Referral” from my Primary Care Physician, I am responsible for obtaining the insurance referral prior to being seen in our office and prior to testing. We recommend that all patients call and confirm this directly with your health insurance or check with your PCP office ahead of time. If an “insurance referral” has not been obtained before my appointment, I will be asked to sign a “Waiver Form” acknowledging that if the referral is not able to be obtained timely, I will be financially responsible for the charges incurred.

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