Thank you for choosing Oregon Sleep Associates as a participant in your healthcare. We are committed to building a successful patient-physician relationship with you, and clear understanding of our financial policy is important to that relationship.
In order to assure that you receive every benefit to which you are entitled, our staff will request you present your current insurance card(s) at each visit.
It is essential for patients to take responsibility for notifying our office of any information changes (i.e. address, name, insurance information, etc.) prior to any appointments, or receipt of durable medical equipment/supplies.
Please come prepared to pay co-payments, deposits, and past-due balances at the time of your visit. For your convenience we accept cash, checks, Visa and MasterCard. Un-paid co-pays may be assessed an administration fee of $25 per appointment. All patient balances are due within 30 days of the statement date, unless prior arrangements have been made with our billing department. Checks returned by the bank will be assessed a $35 fee, payable by cash or money order. A list of fees is available upon request.
Insurance is a contract between you and your insurance company. Please take the time to review your health insurance policy. We are not a party of this contract. We will bill your 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. Although we estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility and benefits. Any amount unpaid by your insurance company becomes your responsibility.
If your insurance plan is one with which we are not a participating provider, you will be responsible for full payment of your account.
authorization for services
Certain insurances require that you obtain a referral or prior authorization from your Primary Care Provider before visiting our office. If your insurance company requires either of these, you are responsible for obtaining it.
late cancel fee
Please contact our office to re-schedule or cancel an office appointment and/or sleep lab appointment. Failure to cancel within 24 hours, or appointments missed, will result in a $50 fee ($150 for the sleep lab) being assessed, per incident, on the patient’s account, which will not be billed to insurance.
Extended payment arrangements are available if needed. Please ask to speak with a billing specialist to discuss a mutually acceptable payment plan, 503-288-5201. It is never our intention to cause hardship to our patients, only to provide them with the best care possible, with the least amount of stress.
I have read, understand and agree to the terms of the above Financial Policy.
Patient Name ____________________________________ Date of Birth __________________________
Patient Signature ________________________________ Date _________________________________