Thank you for choosing Telemedora, PC for your sleep care. Telemedora, PC is committed to providing you with quality and affordable health care.  Every patient is required to review and sign this agreement.  Please read the following information closely.  If you have any questions, please ask.  A copy will be provided to each patient upon request and will be retained in medical record. 

PLEASE READ AND SIGN WHERE INDICATED – THIS DOCUMENT DESCRIBES YOUR FINANCIAL RESPONSIBILITIES. 

THIS IS A LEGALLY BINDING CONTRACT BETWEEN TELEMEDORA, PC AND YOU. THE WORDS, I, ME, MY, YOU AND YOUR ALL REFER TO THE PATIENT.
I UNDERSTAND AND ACKNOWLEDGE THAT IT IS MY RESPONSIBILITY TO KNOW WHAT THE TERMS OF MY INSURANCE ARE, AND IN COMPLIANCE WITH THOSE TERMS, AGREE THAT:

1. Insurance: Telemedora, PC accepts Medicare and some commercial insurances. While Telemedora may have an agreement with your insurance, it is your responsibility to know if your plan is in network.  If your plan requires a referral, you must obtain it prior to your visit. By contract, covered charges will be paid directly to Telemedora, PC. 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 the costs of all services provided. If your insurance is not a plan we participate in, payment in full is expected at each visit. 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, etc. In this case, you may receive a separate bill from an external company, which will be your responsibility.

2. Patient payment: All co-insurance payments and deductibles are to be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure to make the appropriate co-payment at the time of your office visit may result in the re-scheduling of your medical appointment.

3. Registration: All patients must complete a patient information form, which will be entered into our computer to maintain accurate information for proper billing.  A copy of your driver’s license and current valid insurance card is required prior to the visit. 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 filing restrictions; if a claim is not received within 30 days of the date of service, it can be rendered ineligible for payment and you will be responsible for the balance that remains.

4. Claims:  For in-network patients, your claims will be submitted to your insurance by Telemedora, PC and we will assist you in any way we reasonably can to help get your claims paid. 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. Please be aware that the balance of your claim is your responsibility whether your insurance company pays or not. Your insurance benefit is a contract between you and the insurance company; we are not party to that contract.

5. For cash patients: Full payment is due at the time of booking an appointment. After the visit, a superbill will be generated. When an account balance becomes your responsibility, the balance is due upon receipt of the first account statement from Telemedora, PC. Any account balance over 90 days will be subject to review for collection action. A $35 returned check fees will be charged for insufficient funds.

6. For out-of-network non-Medicare patient:  Full payment is due at the time of booking an appointment.  When an account balance becomes your responsibility, the balance is due upon receipt of the first account statement from Telemedora, PC.   Any account balance over 90 days will be subject to review for collection action. A $35 returned check fees will be charged for insufficient funds.

7. Credit and collection:  If your account is more than 90 days past due, you will receive a letter stating that you have 20 days to pay your account in full. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance has remained unpaid, it may be sent to a collection agency. If an account 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 regular and certified mail that you will have 30 days to find alternative medical care. During that 30-day period our physicians will be able to treat you only for emergent needs.
8. Credit 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 a credit card/debit card on file with our office. We will send you a secure link, which will allow you 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 pay copays, deductibles, account balances, after your insurance processes your claim and cancellation fees, etc. 

If we do not receive payment for the amount listed on your statement within 60 days, we will run the credit card on file for the full amount owed. If your payment is declined, we will call you.  If our reminder call is not returned within one week, a $35 declined payment fee will be applied and another statement will be mailed. Your account becomes delinquent if not paid within 30 days after the date of the original statement.  The unpaid balance will be subject to a charge of $35, whichever is greater. Further delinquency will be subject to collections with additional finance fees.

9. Missed appointments and late cancellation:  There is $75 fees for missed appointments or when 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.

 

I ALSO ACKNOWLEDGE, AGREE AND UNDERSTAND THAT: 

 
1.     I am financially responsible for the payment of Telemedora, PC’s services.
2.     It is my responsibility to determine whether services of Telemedora, PC are covered by my insurer.
3.     Current insurance cards along with a valid driver’s license must be presented at every office visit (virtual).
4.     I agree to give Telemedora, PC my complete and accurate insurance information for primary and secondary insurance benefits including referral documents from other providers, if needed. I understand that if I fail to give complete and accurate information about my insurance benefits this may result in a denial of my claim or a delay in payment. I agree to pay Telemedora, PC the balance on my account after my insurance claim has been processed.
5.     I will pay at the time of service any required co-payments, co-insurance and deductibles, as well as charges for services not covered by insurance, outstanding balances and delinquent accounts.
6.     I will pay the cost of any service that is not covered by my insurance for any reason or are covered but applied to a deductible.
7.     I assign to Telemedora, PC all healthcare benefits to which I am entitled under any insurance policy or benefit plan and authorize payment of benefits directly to Telemedora, PC. 
8.     I hereby 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 provider.
9.      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.
10.   If I have insurances that Telemedora, PC is in-network with, then Telemedora, PC will submit a claim to my insurer and allow 60 days for a response. If my insurer 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 me for the visit charges.
11.   By providing my credit card information and receiving telehealth services, I (i) authorize Telemedora, PC to charge my credit card for any and all unpaid amounts that Telemedora, PC or my insurer determines are my responsibility, and (ii) agree to pay all amounts charged pursuant to this consent and authorization in accordance with the issuing bank cardholder agreement. I agree that Telemedora, PC may charge my credit card for such amounts.
12.   I will be billed for all unpaid balances deemed by Telemedora, PC or my insurer to be my responsibility and agree to pay such amounts in full.
13.   If my insurance plan requires a referral, I must obtain it prior to my visit.
14.   I agree that if my insurance benefit requires me to provide a referral and if the referral is not in place before my appointment, that I will pay in advance an estimate of charges for my office visit or reschedule my appointment.
15.   I understand that all services provided to me by Telemedora, PC are considered medically necessary, if I do not comply with my provider’s instructions it may be against medical advice and may void my insurance benefits. Should this occur, I agree to pay the balance remaining on my account after my insurance has been processed.
16.   I understand that I will be responsible for fees of $75 for any missed appointments or any cancelled appointments in which two business days’ notice prior to the appointment was not given.
17.   I understand there will be a $35.00 fee for all returned Checks.
18.   I understand that my insurance may or may not agree to the usual, customary or reasonable charges for my local area. I understand that my benefits may not cover all services or might deny payment for services that have been approved of in advance. I agree to pay the balance remaining on my account after insurance has been processed.
19.   I agree to pay any balance remaining on my account for any reason upon receipt of a statement and I understand that when requested, I must give Telemedora, PC my current address and other contact information. I understand that if I fail to pay the balance on my account this may result in Telemedora, PC pursuing any collection means possible.
20.  I give Telemedora, PC permission to charge my credit card for any patient balance due on my account. If I have insurance coverage, my card will be charged AFTER my insurance has paid their portion.

21. If my account becomes delinquent, it may be forwarded to an outside collection agency. If this happens, I will be responsible for all costs of collection, including but not limited to interest, rebilling fees, court costs, attorney fees, and collection agency costs.
22.   If the reason for my appointment is related to a work injury or auto accident, I agree to provide Telemedora, PC with the case number or policy number, the workman’s compensation or insurance carrier’s name, address or other contact information at the time of my appointment so that Telemedora, PC can bill workman’s compensation or the auto insurance carrier for my visit. If I do not provide this information at the time of the visit, I agree to pay all charges for my visit.
 
I HAVE READ AND I UNDERSTOOD TELEMEDORA’S FINANCIAL AGREEMENT AND I AGREE TO BE 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 my physician. 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 understand that my signature requests payment be made to pay my claim. 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 regarding 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 FINANCIAL POLICIES AND I ACCEPT RESPONSIBILITY FOR THE PAYMENT OF ANY FEES ASSOCIATED WITH MY CARE.