New Patient Form

Sleep Clinics in Gainesville and Lake City

New Patient Form

In order to serve you properly we will need the following information. All information will be kept strictly confidential.

Step 1 of 6

16%
  • Lifetime Assignment of Benefits/Information Release/Authorization to Treat Financial responsibility

    I authorize payment of medical benefits to Sleep Solutions for any services furnished. I understand that I am financially responsible for any amount not covered by my insurance carrier. I authorize you to release to my insurance company or its agent information concerning health care, advice, treatment or supplies provided to me. This information will be used for the purpose of evaluating and administering claims or benefits.

    I also authorize the interdisciplinary team to perform the treatments or procedures approved by my referring physician. I acknowledge and fully understand that no guarantees, either expressed or implied, have been made to me regarding my diagnosis, treatment, the procedures used, and alternatives available, if any.

    We will bill your insurance company for the chargers of any procedure and you will be responsible for any difference in payment coverage. Many times insurance companies do not give us accurate coverage information and a credit card may be required to be kept on file for payment of any fees not covered by your insurance company.