AOB form

Please correct the errors described below.

APPOINTMENTS

If you do not have your insurance information or we are unable to verify your coverage you will be required to pay for the services rendered to you that same day.

• Annual visits, at minimum, are required for continuation of medication refills or CPAP supplies. The administration of some medications may require 3 month visits, even once established.

• Medication: If it has been over 12 months, patient will be given 1 month refill & notice that appointment must be made and kept to continue medication refill. If the patient does not keep their appointment, a titration dose will be ordered and written for 2nd month. Then the medication will be discontinued.

• CPAP supply orders: DME orders will not be renewed if the patient has not been seen in the past 12 months. Most insurance companies require a face to face visit for new CPAP machine (not supplies).

• Cancellation Policy: We charge $50 for missed appointments or canceled appointments with less than 24 hours notice. All charges for canceled/missed appointments must be paid prior to being rescheduled.

MID LEVEL PROVIDER

Our practice utilizes both physicians and advanced practice nurses in patient treatment. Our nurses, (Nurse Practitioner (NP) or Clinical Nurse Specialist ( CNS ) are referred to as Mid Level Providers. They treat and diagnose patients under the supervision of a licensed physician. Their license also allows them to prescribe medications and order any necessary tests.

PATIENT PORTAL

Our chosen Electronic Health Record (EHR) system is called Azalea Health. With Azalea, we can share critical parts of your record with you through a secure patient portal. Currently, the information you can retrieve by using the patient portal includes:

• Insurance information

• Medication list and drug allergies

• Vital statistics (such as heart rate & blood pressure)

• View & UPDATE your personal contact information

Email communication involving medical information: For security purposes, we do not initiate contact with patients through email. For our practice, phone calls and face to face visits are appropriate methods of communication. We provide a secure means of communication through the Azalea patient portal for all patients and you are encouraged to sign up for easy access to your account. Please provide your email address where we can send the Patient Portal invitation.

Forms: We prefer that forms be brought to your appointment so we can review it together (examples: for Disability, FMLA and Job or School). Your provider will determine any fee for this service, typically $50. Some forms require considerable provider time outside of the visit and fees can go as high as $150.

MEDICATIONS & TREATMENT OPTIONS

We prescribe controlled substances for many of our patients. Government guidelines for controlled substances are very strict and demand greater administrative oversight than non-controlled substances. Due to the nature of our specialty practice and a large patient population, this has had a profound effect on staff time. We require (5) business days in order for prescription refills to be completed. There is a $30 fee for emergency (same day) refill requests to be processed.

E-Prescribing - This practice uses electronic prescribing of certain medications. This method of prescribing allows us to connect with your pharmacy and share information regarding your medications

Prior Authorizations: If your insurance denies medication we prescribed (usually because they do not include it on their “approved” medication formulary list) we can prescribe an alternative medication that is on your insurance company's "approved" list or we can attempt to get our recommended medication approved by going through the insurance company’s Prior Authorization process.

Appeals: The last option if Prior Authorization is denied is to file an appeal.

Patients requesting a 2nd Opinion from another sleep practice: If you need medical records sent to another sleep practice for a 2nd opinion you must share that information with your SMC provider. We are open to 2nd opinions from our peers but you should be treated by only one sleep practitioner. Without this advance notice, should we receive a request for your records from another sleep practice, we will consider this to be a transfer of care and will not continue to provide treatment and refill prescriptions.

FINANCIAL POLICY

Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our Financial Policy, which we require new patients to read and sign prior to any treatment.

• Regarding Insurance - Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. As a courtesy to our patients, we will submit a claim to your insurance company. If you have insurance coverage with one of the plans we participate with, we will bill your insurance company along the guidelines of our contract. ALL CO-PAYS and OUTSTANDING balances are expected to be paid at the time of service. If you have an insurance with which we do not participate, we ask that payment be made at the time services are rendered and we will provide you with appropriate paperwork to submit to your insurance company for any reimbursement they allow. Please be aware that some, and perhaps all, of the services provided may be non-covered services and not considered reasonable and necessary under the Medicare Program and/or other medical insurance. Our office will make every effort to predetermine eligibility prior to your visit, but you are ultimately responsible for your bill. We accept cash, checks, Visa, MasterCard, American Express or Discover.

• Returned Checks & Outstanding Balances: Return checks are subject to a $50 return check charge. After 2 returned checks, payment must be one of the following methods: cash, money order, debit/credit card. Balances older than 60 days will be turned over to Merchants and Professional Credit Bureau.

Insurance Referral Authorizations: If we are in-network with your insurance company and your appointment requires authorization, you will need to have the authorization/referral initiated by your primary care provider (PCP) prior to your appointment. If not, your insurance company will not cover the visit and you will be responsible for a higher portion (out of network) or for the full charge. It is your responsibility to obtain the authorization/referral in advance if your appointment requires one.

Assignment Of Benefits

By my signature below, I authorize SMC (Sleep Medicine Consultants) to apply for benefits on my behalf for covered services rendered by SMC and request that payment be made directly to SMC. I authorize the release of any medical information necessary to process claims. I understand that I am responsible for payment of any insurance deductibles, coinsurance and services that are not covered due to contract limitations for the account of the patient listed below. I permit a copy of this authorization to be used in place of the original. I have read, understand, and agree to the Financial Policy for Sleep Medicine Consultants. I have also been informed of SMC Office Policies and Cost of additional services outside of a normal office visit.

HIPPA

HIPAA POLICIES ►Phone Communication: Please provide a phone number in case a Provider or office staff member needs to reach you:

► IN CASE OF AN EMERGENCY: Who should we contact?

HIPAA Right of Access for Family Member/Friend: I direct my health care and medical services providers to disclose and release my protected health information to:

HIPAA Notice of Privacy Practices Acknowledgement - SMC is required by law to protect the privacy of health information that may reveal your identity. A copy of our Notice of Privacy Practices provided upon request. Your signature indicates 1) we have made a copy of the Notice of Privacy Practices available to you, 2) you understand that we keep medical records electronically and you have access to a secure patient portal, and 3) you understand that we will electronically connect to your pharmacy to submit and obtain medication information.

HIPAA Policy Acknowledgement:

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