Thank you for choosing NeoSleep, LLC and Dr. Chimoskey as your healthcare provider. We are committed to providing you with the highest quality healthcare. We ask that you read and sign this form to acknowledge your understanding of our patient financial policies.
Patient Financial Responsibilities:
The patient, (or patient's guardian, if a minor), is ultimately responsible for the payment.
We do not accept all insurances. We do not currently accept Aetna, Humana or Medicaid. There are other insurances we do not accept. It is up to the patient to check and make sure that we are in network for your insurance.
We will bill your insurance for you if we are participating with your insurer. We will not bill insurers where we are not participating and the patient will be considered self-pay. The patient is required to provide the most correct and updated information regarding insurance. Patients are responsible for payment of co-pays, co-insurance, deductibles and all other procedures or treatments not covered by their insurance plan. Co-pays are due at the time of service. Co-insurance, deductibles and non-covered items are due 30 days from the time of billing. Patients may incur, and are responsible for payment of additional charges, if applicable. These charges may include: a charge for returned checks and a charge for missed appointments without 24 hours' notice.
Patients with obstructive sleep apnea that use CPAP may be charged a monthy fee for monitoring those devices. This fee may or may not be covered by the patient's insurance.
By my signature below, I hereby authorize assignment of financial benefits directly to NeoSleep, LLC and any associated healthcare entities for services rendered as allowable under standard third-party contracts. I understand that I am financially responsible for charges not covered by this assignment.
I have read, understand, and agree to the provisions of the Patient Financial Responsibility as described above.