Effective May 1, 2022, we now require a credit card to be on file with our office for every patient.
Please understand that as health care providers our relationship is with you. Your insurance policy is a contract between you and your insurance company; we are not a party in that contract. Although we are in-network with several insurance companies, it is your responsibility to make sure that your policy will cover the services you receive at our office. If our office is not a participating provider for your plan, you may still select our office for your medical care, and "out of network" benefits will apply (if your plan has them). It is your responsibility to know your insurance benefits. Please contact your insurance company at the customer service number printed on your insurance card if you have questions pertaining to your coverage.
As we have done in the past, we will continue to bill your insurance and you will then get a statement for the portion that your insurance determined is the patient's responsibility. If the balance is not paid within 30 days from the date of the first statement, we will then bill the credit card on file. A receipt will be available upon request. In order to be seen for another appointment, you must pay any outstanding balances in full (even if within 30 days from the date of the first statement). If you receive a statement that you feel is incorrect, please contact us immediately so we can look into whether our office or your insurance company made an error. If an error was made by your insurance company, we will ask you to contact them to resolve the issue.
Expiration Date: One (1) year from your Date of Service.
I agree to allow Sleep Solutions of North Florida to keep my credit card on file and to charge my credit card for any outstanding balance on my patient account. This includes co-pays, deductibles, co-insurance, non-covered services, late fees, unreturned equipment, and cancellation fees. I acknowledge that:
- My credit card will be charged 30 days after the first statement is sent following review of the final explanation of benefits from each applicable insurance company for services provided while this agreement is in effect
- If my credit card is declined, Sleep Solutions of North Florida will bill me directly for any outstanding balance. I acknowledge that I will not be able to schedule any future appointments with Sleep Solutions of North Florida until the balance has been paid in full. If the balance is not paid, I understand that my account may be sent to a collections agency and that I and my family members may be discharged from the practice.
- I am responsible for informing Sleep Solutions of North Florida of any updates regarding my insurance or credit card information.
- I may request a receipt detailing the amount charged.
- I may cancel this agreement at any time by contacting Sleep Solutions of North Florida; any unpaid amounts relating to service provided while this agreement is in effect will then be billed to me directly.
*Adding your card on file will not create a charge on your card
**We require a card on file for every patient even if you do not owe a copay