Insurance Information

Responsible party information if under 18 years of age

Emergency Contact

I consent to the use or disclosure of my personal health information by Sleep Disorders Center of Connecticut, LLC, for the purpose of diagnosing and providing treatment to me, obtaining payment for my health care bills, or to conduct health care operations of the practice. I understand that diagnoses or treatment of me by the Center may be conditioned upon my consent as evidenced by my signature on this document.

I understand that the Center had created a Notice of Privacy Practices that provides a more complete description of the intended uses and disclosures by the Center. I have a right to review the Center’s Notice of Privacy Practices prior to signing this document. The Center’s Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bill, or in the performance of health care operations of the Center.

I understand I have the right to request a restriction as to how my protected health information is used and disclosed to carry out treatment, payment, or health care operations of the Center. The Center is not required to agree to the restrictions that I may request. If the Center agrees to a restriction that I request, however, the restriction is not binding on the Center.

I have the right to revoke this consent, in writing at any time, except to the extent that Sleep Disorders Center of Connecticut, LLC, has taken any action in reliance to the consent.

My “protected health care information” means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or health care clearing house. This protected health care information related to my past, present, or future physical or mental health or condition that identifies me, or there is a reasonable basis to believe the information may identify me.

The Notice of Privacy Practices for the Center is also provided and available to me for my review if requested by me. This Notice of Privacy Practices also describes my rights and the Center’s duty with respect to my protected health information.

The Center reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised Notice of Privacy Practices by calling the office and requesting a revised copy be sent to me by mail, or asking for on at the time of my next appointment.

Signature of Patient or Personal Representative :

Patient Name: D.O.B:

IMPORTANT: THIS IS NOT AN APPLICATION FOR CREDIT. CHARGES FOR ALL SERVICES RENDERED BY Hamden Sleep Disorders Center dba Sleep Disorders Center Of Connecticut, and PULMONARY CARE,PC , ARE DUE AND PAYABLE IN FULL SIXTY DAYS FROM THE DATE SERVICES WERE RENDERED. We will assist the patient in processing of the claims as a courtesy only. A credit card will be kept on file for all patients with deductible and co-insurance. We accept no responsibility for any processing procedures, acts, omissions and/or neglect. PATIENT AND RESPONSIBLE GUARDIAN ARE SOLELY RESPONSIBLE TO PAY FOR ALL SERVICES PROVIDED. In consideration of the provision of the services patient, names herein, the patient and the responsible party understand and agree that:

• 1. Payment for services rendered is due in full Sixty (60) days from the date service was rendered. Any unpaid balance after sixty days will be considered “delinquent”.
• 2. The patient and the responsible party must pay all costs of collection, including reasonable attorney’s fees, if the delinquent balance is referred to an attorney for collection.
• 3. ANY BALANCE UNPAID AFTER NINETY (90) DAYS FROM THE DATE SERVICES WERE RENDERED WILL BE SUBJECT TO INTEREST AT THE ANNUAL PERCENTAGE RATE OF Twelve (12%) PERCENT WHEN THE ACCOUNT HAS BEEN PLACED FOR COLLECTION.
• 4. In the event the patient submits payment by check and that check is returned for insufficient funds by the bank, we will add THIRTY FIVE ($35.00) dollars to the balance owed by the patient.
• 5. This agreement shall be binding upon the patient and the responsible party for all charges incurred by the patient for a seven (7) year period from the date of this agreement.
• 6. No statement by an employee or agent will contradict, void, or nullify this agreement, nor shall the patient rely on any statement or opinions made by us that an insurance carrier will pay the bill.
• 7. Patients who do not show up on time for an office appointment, or cancel with less than 24 hours notice will be charged a $50 fee. If you do not show up for your sleep study or cancel within less than 48 hours notice, you will be charged a $200 fee.
• 8. It is entirely the patient’s responsibility to know their co-payment or deductible amounts and notify the sleep center before the services are rendered. Also patient is fully responsible to get a referral from his/her physician if required by the insurance carrier.

Authorization is hereby given the Hamden Sleep Disorder Center and Sleep Disorders Center of Connecticut, LLC, to submit my claim directly to my insurance on my behalf. I understand that by signing this form my signature is not needed each time a claim is submitted on my behalf. I further authorize my insurance carrier to forward payment directly to Hamden Sleep Disorder Center and Sleep Disorders Center of Connecticut. I HEREBY AUTHORIZE YOU TO RELEASE ALL MEDICAL AND BILLING INFORMATION NECESSARY TO SECURE PAYMENT FROM ANY INSURANCE CARRIER, ON MY BEHALF.

I have read and fully understand all the above conditions. Once I sign this Agreement, I am responsible for all charges, and if necessary, cost of collection and a reasonable attorney’s fee, as stated above: I acknowledge receipt of copy of this Agreement:

Dated: Witness:
Patient:

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