I am responsible for providing up to date and accurate insurance information to Capitol Sleep Medicine, LLC. I certify the information given by me in applying for payment under Title XVIII of the Social Security Act (Medicare) or under the terms of any other insurance carriers is correct. If your insurance changes I will notify Capitol Sleep Medicine within 10 days of this change. I understand that failure to do so may result in me being billed for any outstanding balances.
I hereby authorize Capitol Sleep Medicine, LLC and / or any of its representatives to submit claims to my insurance carrier or its intermediary for services rendered to me and authorize payment be made directly to Capitol Sleep Medicine, LLC. I hereby authorize release of any information necessary to process medical claims. I authorize release of medical information necessary for continuity of care to Home Medical Equipment companies as recommended by my medical provider.
I understand that my insurance carrier will assign benefits to Capitol Sleep Medicine, LLC. I understand and certify that I am financially responsible for all health care service charges that are paid to me directly by my insurance carrier as well as for any applicable copayments, coinsurance, deductibles, and / or charges for non covered goods and services provided to me or to any of my dependents.
I will pay any and all charges due and owing Capitol Sleep Medicine, LLC in accordance with their regular rates, terms, and policies.
By signing below I certify that I will pay to Capitol Sleep Medicine, LLC any copayments, coinsurance, deductibles, or non covered goods and services. I will immediately pay to Capitol Sleep Medicine, LLC any payments I receive from my insurance for services provided by them to me or my dependents. I will also be responsible for any amounts not paid by my insurance due to my failure to provide Capitol Sleep Medicine, LLC appropriate insurance information for billing.