Thank you for choosing Telemedora, PC for your sleep care. Telemedora, PC is committed to providing you with quality and affordable health care. Your clear understanding of our Patient Financial Agreement is important to our professional relationship. Please understand that payment for services is an essential part of that relationship. Every patient is required to review and sign this agreement prior to receiving any service from Telemedora, PC. A copy will be provided to each patient upon request and will be retained in the medical record.

THIS DOCUMENT DESCRIBES YOUR FINANCIAL RESPONSIBILITIES.  PLEASE READ THE FOLLOWING INFORMATION CAREFULLY AND SIGN WHERE INDICATED.

THIS IS A LEGALLY BINDING CONTRACT BETWEEN TELEMEDORA, PC AND YOU. THE WORDS, I, ME, MY, YOU AND YOUR; ALL REFER TO THE PATIENT.

Please ask if you have any questions about our fees, our policies, or your responsibilities. It is your responsibility to notify our office of any patient information changes (i.e. address, name, insurance information, etc.).  

1. Registration:  At the time of booking your initial appointment, you must provide us with your current contact information including your address, mailing address, phone and email; copies of front and back of your current valid driver’s license, current primary and secondary insurance cards. If you fail to provide us with the correct insurance information, or your insurance changes and you fail to notify us in a timely manner, you may be responsible for the balance of a claim. Most insurance companies have time-sensitive claim filing restrictions; if a claim is not received within 30 days of the date of service by your insurance, it can be rendered ineligible for payment and you will be responsible for the balance that remains.

2. Credit Card/Debit Card On File (For Non-Medicare Patients): Telemedora, PC is committed to making your billing process as simple and easy as possible. We require that at the time of scheduling an appointment, non-Medicare patients provide us with their credit card/debit card info to be kept on file with our office. We will send you a secure link, which will allow you to enter your credit card information. This information will be encrypted and processed by our payment processing partner.  For security reasons only the last four digits will be visible to our staff. Credit cards on file will be used to collect your financial responsibility including copays, co-insurances, deductibles, account balances, cancellation fees, etc.  By providing your credit card/debit card information and receiving services, you (i) authorize Telemedora, PC to charge your credit card/debit card on file if no payment is received from you within TEN (10) calendar days of mailing an invoice to you, for any and all unpaid amounts that Telemedora, PC or your insurer determines are your responsibility, and (ii) agree to pay all amounts charged pursuant to this consent and authorization in accordance with your issuing bank’s cardholder agreement. 

3. Missed appointments and late cancellation:  There is a $75 fee for missed appointments or when an appointment is cancelled within two business days before your scheduled appointment. These charges will be your responsibility and billed directly to you. Please help us serve you better by keeping your scheduled appointment.

4. Insurance: Telemedora, PC accepts traditional Medicare in California and some commercial insurances. In some other states, we are in-network with some commercial insurances. While Telemedora may have an agreement with your insurance, it is your responsibility to know if we are in-network with your plan or not.  By contract, covered charges will be paid directly to Telemedora, PC. Certain health insurances (HMO, POS, etc.) require that you obtain a referral or prior authorization from your Primary Care Provider (PCP) before visiting a specialist. If your insurance company requires a referral and/or preauthorization, you are responsible for obtaining it. Failure to obtain the referral and/or preauthorization may result in a lower or no payment from the insurance company, and the balance will become your responsibility. If you fail to obtain the referral and/or preauthorization, you agree to pay in advance an estimate of charges for your appointment, otherwise, your appointment will be rescheduled until you obtain the referral and/or preauthorization required by your insurance.

5. Insurance claims:  Insurance is a contract between you and your insurance company. In most cases, we are NOT a party to this contract. If we are in-network with your insurance, then estimated cost of visit including but not limited to co-insurance, co-pay and deductible, etc. will be provided to you prior to the service. You are required to pay this estimated cost  at the time of service. Failure to pay co-insurance, co-pay and deductible at the time of your appointment may result in the re-scheduling of your medical appointment.   We will bill your primary insurance company as a courtesy to you. In order to properly bill your insurance company, we require that you disclose all insurance information including primary and secondary insurance, as well as any change of insurance information. Failure to provide complete insurance information may result in patient responsibility for the entire bill. Your insurance company may not accept information from our office and may need information from you. It is your responsibility to comply with their request.  We will allow 60 days to your insurance company for a response. If your insurance company  does not respond within 60 days, Telemedora, PC will assume that the visit is not covered and will, to the extent permitted by law, bill you for the visit charges. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility and benefits.  Please be aware that the balance of your claim is your responsibility whether your insurance company pays or not. 

6. Co-pay, deductible, co-insurance and outstanding balance, etc: You are required to present an insurance card(s) at each visit. All co-payments, deductible, co-insurance, past due balances, delinquent accounts as well as charges for services not covered by insurance for any reason are due at time of check-in. We accept checks, credit cards or debit cards. Absolutely no post-dated checks will be accepted. 

7. Patient responsibility for “Not payable” or additional medical services:   In the event that your health plan determines a service to be “not payable”, you will be responsible for all the charges and agree to pay in full the costs of all services provided. Please contact your insurer with any questions you may have regarding your coverage to receive the maximum benefit. During your appointment, your provider may order additional medical services, such as laboratory tests, radiology, sleep study, etc. In this case, you may receive a separate bill from an external company, which will be your responsibility.

8. Self-pay Accounts: Self-pay accounts are patients without insurance coverage, patients covered by insurance plans in which the office does not participate, or patients without an insurance card on file with us. Liability cases will also be considered self-pay accounts. We do not accept attorney letters or contingency payments. It is always the patient’s responsibility to know if our office is participating with their plan. If there is a discrepancy with our information, the patient will be considered self-pay unless otherwise proven. If your insurance company is not contracted with us, you agree to pay any portion of the charges not covered by insurance, including but not limited to those charges above the usual and customary allowance. If we are out of network for your insurance company and your insurance pays you directly, you are responsible for payment and agree to forward the payment to us immediately. When an account balance becomes your responsibility, the balance is due upon receipt of the first account statement from Telemedora, PC.   

9. Motor Vehicle Accident (MVA) and Third-Party Billing: We do not do any third-party billing. Our relationship is with you and not with the third-party liability insurance (auto, homeowner, etc.). It is your responsibility to seek reimbursement from them. However, at your request, we will submit a claim to your primary health insurance carrier. You may receive an accident questionnaire from them to be completed by you. If the questionnaire is not returned to your medical insurance company and/or we receive a denial on your claim, you will be responsible for payment in full.

10. Payment and Collection: You are financially responsible for the payment of Telemedora, PC’s services.  EXCEPT FOR MEDICARE PATIENTS WITH NO DEDUCTIBLE, NO SERVICE WILL BE GIVEN TO PATIENTS WITHOUT FIRST COLLECTING PAYMENT. PARTIAL PAYMENTS ARE NOT ACCEPTED.  You understand that your insurance may or may not agree to the usual, customary, or reasonable charges for your local area. You acknowledge that your benefits may not cover all services or might deny payment for services that were approved in advance. You agree to pay any remaining balance on your account after the claim has been processed. You understand that all services provided to you by Telemedora, PC are considered medically necessary. If you do not comply with your provider’s instructions, it may be considered against medical advice and could void your insurance benefits. Should this occur, you agree to pay any remaining balance on your account after your insurance  claim has been processed. Upon receiving an explanation of benefits from your insurance, if you still owe us money, we will send you an invoice of the balance due. You are required to pay the balance due within TEN (10) calendar days from the date of invoice. If no payment is received from you within TEN (10) calendar days then your credit card/debit card on file will be charged for the amount owed by you. Please be aware that if a balance has remained unpaid for 30 days, it may be sent to a collection agency. If this happens, you will be responsible for all costs of collection, including but not limited to interest, rebilling fees, court costs, attorney fees, and collection agency costs. If an account remains unpaid for 30 days or is sent to collection, it is the policy of this office to discharge the patient and possibly immediate family members from the practice. You will at that time be notified by USPS regular and certified mail that you will have 30 days to find alternative medical care. During that 30-day period Telemedora, PC will be able to treat you only for emergent needs. 

11. Refund: On rare occasions, your visit may cost less than the amount we collected at the time of service. In this case, once your insurance processes the claim, we will refund to you the excess amount collected or if you prefer, we can leave it as a credit on your account. Because of the effort put into calculating patient responsibility for each patient visit, our over-collection rate is less than 2%.  

12. Late, partial or declined payment fees: If your payment is declined, a $35 declined payment fee will be applied and another statement will be mailed.  If complete payment of the entire amount due is not  received within 30 days from the date of the original statement, your account will become delinquent. The unpaid balance will be subject to a charge of $35 or 10% of balance owed, whichever is greater. Further delinquency will be subject to collections with additional fees.

13. Filling out forms: As a specialist office, we do not fill out FMLA or EDD forms and you will be directed to your Primary Care Provider to get these forms filled. However, if you want us to fill out any other forms, for e.g. (PG&E, etc.), a fee of $75 per form will be charged. 

14. Medical Record Copies: Patients requesting copies of medical records will be charged:

$10 – 10 to 20 pages 

$15 – 21 to 49 pages 

$20 – Over 50 pages 

Burning of CD’s, Attorneys and Insurance companies will be charged a $25 fee for Medical Records and/or Itemized bills.  Please allow 5-7 business days to complete your request. Every effort will be made to complete your request in a timely manner. If your forms are completed prior to the 5-7 business day timeframe, you will receive a phone call to inform you of the completion. If you have an urgent need for these services, please let us know of your need at the time of the request.

I ATTEST THAT I HAVE READ, ACKNOWLEDGED AND UNDERSTOOD TELEMEDORA’S FINANCIAL AGREEMENT AND I AGREE TO BE LEGALLY BOUND BY ITS TERMS. I ACCEPT RESPONSIBILITY FOR THE PAYMENT OF ANY FEES ASSOCIATED WITH MY CARE. I UNDERSTAND THAT MY REFUSAL TO SIGN THIS FORM WILL BE INTERPRETED AS MY DECISION TO CEASE RECEIVING MEDICAL CARE FROM TELEMEDORA, PC.

ASSIGNMENT OF BENEFITS (INCLUDING MEDICARE BENEFITS):

I hereby authorize direct payment to be made on my behalf to Telemedora, PC for any services provided to me by Telemedora, PC or its employees. This is a DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS. This authorization will remain in effect until cancelled by me in writing. I authorize my provider to release to the Health Care Financing Administration and its agents any information needed to determine my benefits and to obtain payment. I also authorize Telemedora, PC to release to my insurance company, payors or their representatives, government agencies or any other entity financially responsible for my medical care, any and all information in my medical record required to process my claims as well as information required for pre-certification, authorization or referral to other medical providers. My signature also authorizes the release of medical information necessary to pay my claim. My signature also authorizes the release of benefits payable and medical information necessary to pay any secondary insurance payer. I understand that my medical record may contain sensitive information including but not limited to substance abuse, mental health, HIV/AIDS, sexually transmitted diseases, sickle cell anemia or other sensitive information. I understand that I am financially responsible for all charges, late fees, interest, attorney fees and collection charges considered patient responsibility by my insurance company. I understand that if I am not insured, I am responsible for the charges of all services provided to me. I authorize Telemedora, PC to deposit checks received on my account when made out in my name.  A copy of this authorization is as valid as the original document. A copy of this agreement is as legally binding as the original agreement.

I HAVE READ AND I UNDERSTAND TELEMEDORA, PC’S PATIENT FINANCIAL AGREEMENT AND I ACCEPT RESPONSIBILITY FOR THE PAYMENT OF ANY FEES.