Please carefully review this financial policy. As a courtesy to our patients, we strive to provide you with an estimate of your financial responsibility but this estimate is not a guarantee of benefits or payment. The insurance benefit information provided by your insurance plan is based on the latest information they have available. Please remember that your insurance plan benefits are a contract between you, your employer and your insurance company. It is in your best interest to know and understand your benefits. Please contact your insurance company and/or your employer’s human resource department regarding any benefit questions you may have.
By signing this form, Fatigue and Sleep Remedies has provided you with an estimated financial responsibility for this procedure which was obtained from your insurance company. You acknowledge that you are aware of this information and agree to be responsible for this estimated cost as well as any other costs related to services provided, including deductible, co-insurance and any other non-covered fees.
Fatigue and Sleep Remedies request that any cancellation and/or rescheduling of your appointment be done at least TWO business days in advance. A $150 fee will be assessed for patients who cancel/reschedule without giving required notice. This fee applies to appointments scheduled less than two business days as well.
I understand that responsibility for payment of medical services in this office for myself and my dependents is mine; due and payable at the time of services are rendered unless financial arrangements have been made. I understand that I am responsible for all costs of collection including attorney fees, collection fees of 30% and court costs. I understand that any unpaid balance will be assessed interest at the rate of 18.00% (1.5% monthly). Insurance claims are filed as a courtesy, but it is my responsibility to see that the claims are paid. I fully understand that I am responsible for payment of fees not covered by insurance. I also assign all benefits to Provider. I authorize the submission of claims without obtaining my signature on each claim submitted. I give my authorization and consent for treatment after having a full explanation of proposed treatment,
alternatives, and risks by my doctor. I have been advised of my privacy rights as provided by the Healthcare Information Portability and Accountability Act of 1996. I hereby authorize this Provider and its employees, agents and assignees to contact me via e-mail, text messaging and to my cellular devices using automated telephone dialing systems.
