PLEASE GIVE THE FRONT DESK YOUR INSURANCE CARDS / PHOTO ID TO COPY FOR YOUR FILE
ASSIGNMENT OF BENEFITS: (Allows us to file for your insurance) I hereby assign all medical, to include major medical benefits which I am entitled including Medicare and private insurance and any other health plans to: Sleep Manatee. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is valid as the original. I understand that I am financially responsible for all charges whether paid by said insurance. I hereby authorize said assignee to release all information necessary to secure payment. I authorize Sleep Manatee to download my medication history and RX benefits into my account from an RX clearinghouse.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
PREVIOUS SURGERIES/DATES
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
We strive to provide excellent medical care to all our patients. To do so effectively and efficiently, we have an appointment cancellation policy that applies to new and existing patients of the practice.
We understand that situations arise in which you must cancel your appointment. It is, therefore, requested that if you must cancel your appointment, give our office at least 24-hour’s notice for the appointment and 48- hours’ notice for testing. This will allow us to offer that time to another patient on our waitlist.
To remain consistent with our mission, we have instituted the following policy.
Follow-up appointment: $50
New Patient Sleep/Weight Consultation: $100
Sleep Study: $250
Sleep Study and MSLT: $500
Home Sleep Test: $100
I understand that all applicable copayments and deductibles are due at the time of service. I agree to be financially responsible and pay in full for all charges not covered by my insurance company. I authorize my insurance benefits to be paid directly to Florida Sleep Specialist/Discover Health for services rendered. I authorize Florida Sleep Specialists/Discover Health representatives to release pertinent medical information to my insurance company when requested or to facilitate payment of a claim.
This signature will act as a lifetime authorization for Medicare.
I have read and understood the above Financial Policy and agree to meet all financial obligations.
DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
Do we have permission to leave the following on your voicemail?
I understand that the person or entity receiving authorized information is not a health plan or health care provider covered by federal privacy regulations, the authorized information may be disclosed by the recipient and may no longer be protected by federal or state law.
I understand that I may revoke this (HIPPA) authorization and that my refusal to sign in no way affects my treatment, payment, enrollment in a health plan or eligibility for benefits.
I hereby acknowledge that I received Sleep Manatee’s Notice of Privacy Practices.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
I understand this authorization may be revoked by me at any time except to the extent the information has already released.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Purpose of visit: Why are you seeking this visit? (for example, I am seeking help to lose weight because of weight related complications, inability to lose weight by other means, desire for professional guidance to lose weight in a healthy manner).
On a scale of 1-10, please indicate to degree to which each of the following applies to you:
Sleep quality (Skip this section if you we are treating you for sleep disorders).
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Your information will be encrypted.