You need anesthesia for your dental treatment - we can help!

Please complete the REM packet of information that was provided to you by your dental office and return the packet to them along with the following:

*A physical or well child check dated within 12 months prior to your dental treatment appointment.-You can have your health care provider fax it to REM at 913-904-0841.

*A copy of the front and back of your MEDICAL insurance card along with the policy holder's name, address and date of birth.-We will check with your medical insurance to see if there is a benefit for the anesthesia and provide you with an estimate.-You are encouraged to check for your benefit as well. The anesthesia code is 00170

*We require any out-of-pocket estimates to be paid in full 1 week prior to the day of treatment.-We accept HSA cards, Debit cards, Credit cards, and Care Credit.

*Please initial each line above, and return to your dental office, confirming that you understand what is needed in order to proceed with scheduling sedation with REM Anesthesia.

We look forward to caring for you and strive to make the experience as comfortable as possible by incorporating values of curiosity, trust, integrity and kindness.

DR. AMBER TIBERIO, CRNA, DNAP

REM Anesthesia, PLLC
7111 W 151^st St, Suite 139
Overland Park, KS 66223

On behalf of the patient identified above, REM Anesthesia, PLLC requests disclosure of the Protected Health Information (PHI) identified below from the following facility or health care provider ("hereinafter the Disclosing Provider"):

REM Anesthesia requests disclosure of the following type of medical records:

History and Physical

This document does not request certain types of information that are subject to special protections under federal and Kansas law (including 42 C.F.R. 164.508, 42 C.F.R. Part 2, K.S.A. 65-5601 et seq., K.S.A. 59-29b79 and K.S.A. 65-6001 et seq.) and Disclosing Provider shall not disclose such information.

Patient Authorization:

I, the undersigned, have read the above and authorize the disclosure of such health information as described herein. I understand that I may refuse to sign this authorization. My treatment, payment, enrollment, or eligibility for benefits may not be conditioned on signing this authorization.

I understand that I may revoke this authorization at any time, except to the extent that action has already been taken in reliance upon it. This authorization will remain in effect for one year from the date of my signature unless I provide an earlier expiration date or an alternative termination event below.

Patient Financial Policy and Authorizations

Thank you for allowing REM Anesthesia, PLLC to be your anesthesia provider. Our mission is to tailor the anesthetic experience to meet your unique needs, while augmenting comfort and safety. Safety is our #1 priority with the ultimate goal of alleviating stress while incorporating our values of curiosity, trust, integrity, and kindness.

The following information is provided to avoid any misunderstanding or disagreement concerning payment for professional medical services. Your clear understanding of our Patient Financial Policy is important to our professional relationship. Please ask if you have any questions about our fees, our policies, or your responsibilities.

Carefully review the following information and return this form to us with your signature and today's date.

Insurance

It is imperative that you provide us with current and accurate insurance information. A copy of your insurance card(s) will be needed at the time your dental provider has referred you for anesthesia. If you fail to provide insurance information, you will be considered self-pay and will be required to make other arrangements.

It is important for you to understand that you have the contract with your insurance carrier, and you will need to help us work with your insurance carrier to expedite the reimbursement process. We consider an insurance card similar to a credit card because you are asking us to bill another party (your insurance) for charges for the services you have been provided. We will not become involved in disputes between you and your insurance carrier. This includes, but is not limited to, disputes related to deductibles, co-payments, non-covered charges and "usual and customary" charges. We will supply information as necessary. As the patient, you are responsible for any unpaid balance not contractually covered by your insurance. You have final responsibility for payment for services provided. Your participation in the process is both essential and encouraged.

If we DO participate with your insurance company, all services performed in our care will be submitted to them, unless we have received prior notification of non-covered services, or you direct us to not bill insurance. All copays, deductibles, and coinsurances are the patient's responsibility and expected to be paid in full prior to treatment.

If we DO NOT participate with your primary insurance company, but we do participate with your secondary insurance company, we will file the insurance claim with both carriers. If we DO NOT participate with your primary or your secondary insurance company, payment will be required prior to treatment.

Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover. It is your responsibility to know if a certain procedure is not covered, please verify with your insurance carrier. We will also assist in checking your benefits. An insurance company may state certain costs are covered prior to the procedure; however, all procedures are subject to claims review by the insurance company. If insurance benefits do not pay the expected amount, the minimum amount due will be the quoted Self-Pay price. It is your responsibility to bring and share any required referrals for treatment prior to your service date. If you do not have the referral, your visit may be rescheduled, or you may be financially responsible.

Payments

ALL OUT-OF-POCKET COSTS WILL BE COLLECTED IN FULL AT LEAST ONE WEEK PRIOR TO TREATMENT. This includes, but is not limited to, patient responsibility of copays, deductibles, coinsurances, and self-pay patients. Your insurance company may require us to collect co-payments at the time of service. For your convenience we accept cash, check, or credit card (MasterCard, VISA, AMEX, or DISC). We are also participating members of Care Credit, a credit card that can help pay for health, wellness, and medical costs with special financing options. We will be happy to discuss this as an option for payment

A Credit Card Authorization From is required to be completed and signed. We will hold this card on file to be used for any balance remaining after your procedure.

Self-Pay

Patients who do not have insurance coverage, have an out-of-network insurance carrier, or choose to not use their insurance, are considered to be self-pay. Self-pay patients are expected to make payment in full at least one week prior to treatment. If treatment time is longer than expected, there will be an additional charge due upon receipt. As a courtesy, the practice offers a discount for self-pay patients. Your signature may be required on a Self-Pay Acknowledgement Form.

Unpaid Balances & Payment Arrangements

If your insurance company has not paid the balance in full or you are unable to pay the balance in full, you will receive a statement notifying you of the amount due, you may call our billing office at (913) 609-0399 to make a payment on your account. REM Anesthesia reserves the right to set the terms, conditions, and to charge interest consistent with state and federal law for any payment arrangement.

If you fail to make payment in full within 120 days, your outstanding balance may be referred to a third party for further collection activity, or it will be filed with Kansas Small Claims Court. Should it become necessary for REM Anesthesia to send a patient's account to a collection agency or to file with the Kansas Small Claims Court, the patient will be responsible for any and all fees associated with the collection efforts of the account, to include reasonable attorney fees, court costs, collection charges, and interest.

Waiver of Patient Responsibility

It is the policy of the practice to treat all patients in an equitable fashion related to account balances. The practice will not waive, fail to make reasonable collection efforts, or discount co-payments, co-insurance, deductibles, or other patient financial responsibility in accordance with state and federal law, and participating agreements with carriers.

Privacy Policy

As required by law, REM Anesthesia maintains a privacy policy dedicated to the protection of our patient's medical information.

Late Arrivals & Missed Appointments

A late arrival, not considered to be the responsibility of REM Anesthesia, will be registered, and worked into the schedule as soon as possible. If the patient is more than 30 minutes late, the appointment may be rescheduled.

        REM Anesthesia will charge a $250 cancellation fee in the event that you cancel your appointment with less than 24 hours' notice or you do not show for your appointment. This fee may also be applied in the event the appointment is cancelled by you after arrival on the day of service at the location where anesthesia services are being rendered. This will be applied to your account. Future appointments will not be scheduled until the cancellation fee is paid.

Minors

Our practice does not treat minors without the presence of a parent(s) or guardian(s). If the patient is a minor (under 18 years of age), the parent(s) or guardian(s) is responsible for full payment and will receive the billing statements.

Divorce Decrees

REM Anesthesia is not party to any divorce decrees, so any outstanding balance is still the responsibility of the patient or the legal guarantor of the patient, in the case of a minor.

Special Form Fees

If you require any special forms to be completed (i.e., FMLA, Work Comp, or Disability) by a provider, the patient/guarantor will be responsible for any fees related to the service. Payment is required prior to the completion of any forms.

Medical Record Copies

Your medical record is the property of REM Anesthesia. If you would like to request a copy of your medical records, for yourself or to be mailed to another provider, please contact our office to obtain the proper Medical Records Request form. Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) REM Anesthesia may charge a reasonable cost-based fee pursuant to 45 CFR 164.524.

REM Anesthesia must emphasize that as healthcare providers, our relationship is with you, not your insurance company. While filing the insurance claims is a courtesy we extend to our patients, all charges are strictly your responsibility prior to the time services are rendered. Therefore, it is often necessary for you to inquire and explore your benefits with your insurance carrier. We do realize that temporary financial problems may affect timely payment, but if such problems do arise, we encourage you to contact us promptly for assistance in the management of your account at (913) 609-0399. REM Anesthesia believes that a good patient-to-provider relationship is based upon understanding and good communication. Thank you for understanding our “Patient Financial Policy”. We appreciate the opportunity to provide you with your health care needs. Your assistance and cooperation will be most appreciated

PATIENT ACKNOWLEDGEMENT & AUTHORIZATIONS
Authorization for Release of Information: With your signature below, REM Anesthesia is hereby authorized to release a complete report of services rendered, diagnosis, findings and details of treatment and progress for the purpose of receiving payment for such services rendered. Recipients of such information may include authorized billings agents, insurance carriers, employer’s workers compensation insurance company, other third-party payers, the Social Security Administration under Title XVIII (18) of the Social Security Act, Professional Review Organizations, or other intermediaries responsible for payment for services rendered. The release of information consent may be revoked at any time by giving written notice. If release of information is refused, the patient will be held responsible for payment of all charges for services rendered.

Authorization for Assignment of Benefits: In consideration of medical services provided, with your signature below, REM Anesthesia is given all rights, title, and interest to the medical reimbursement in accordance with the terms and benefits of the patient’s insurance policy or other health benefit including Medicare Part B. The patient will be fully responsible for payment of any and all charges not covered by insurance.

Authorization for Treatment: With your signature below, REM Anesthesia is hereby authorized to conduct examination, perform procedures as are medically required and administer treatment and medications as deemed necessary or advisable.

I have read this Financial Policy and Authorizations. I understand the terms and conditions outlined herein as confirmed by my signature below.