I accept full financial responsibility for all charges billed and guarantee payment of all such charges. I understand that if I am not covered by insurances or a not a member of a participating network of which Commonwealth Sleep Center. , is an authorized provider, than I must make full payment at the time of service. I authorize Commonwealth Sleep Center to submit any and all charges to my insurance company on my behalf. I authorize and assign any insurance benefits to be paid directly to Commonwealth Sleep Center, as may be required or requested by any insurance company or other reimbursing entity. I understand that it is the policy of Commonwealth Sleep Center to only release the "minimum necessary information" to accomplish the intent of the interest of the request. I authorize that a photography of this assignment shall be accepted agency for payment, I further agree to pay, beyond the outstanding balance, all attorney fees or collection fees relating to the account. I further understand that future medical care and treatment by Commonwealth Sleep Center may be denied if the account falls more than ninety day pass due.
I understand that it is the policy of this practice that I must give a minimum of twenty-four hour notice if it became necessary for me to cancel an appointment. In the event that twenty-four hour notice is not given, I understand that I will be billed a twenty-five dollar charges for any missed appointment. I further understand that this charges is my financial responsibility. It is not billable to the insurance company. I understand that there is twenty-five dollar charge for returned checks. This return checks charge in my responsibility. It is not billable to the insurance company.
I authorize Commonwealth Sleep Center , to release or disclose any protected health information, for the purpose of treatment, payment, and other health care purposes. I acknowledgement that I have received and reviewed a copy of the "notice of privacy practices of Commonwealth Sleep Center , as required under public law, 104-191, The Health Insurance Portability And Accountability Act of 1996 (HIPAA) (by initializing here you indicate that you have reviewed a laminated copy of our office's privacy notice. If you desire a have a copy of thihis notice to keeping your own files, simply ask the receptionist at the front desk and she/he will be happy to provide a copy to you.)
I understand that the only the signatories to this document are authorized to act as the personal representative of the identified patient and these are the only individually able to secure medical treatment and services on the patient's behalf. All other persons must be listed on separate consent form. This consent form is available upon request from the receptionist.I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If item 12 of HCFA 1500 claim form is completed, my signature authorizes releasing of the information to the insurer or the agency shown. For Medical Patients I understand. I agreed to personally and fully responsible for payment of these charges.
I certify that I have read and understand all of the above information and agree to the policies and practices of Commonwealth Sleep Center, LLC.