Patient Financial Responsibility Form v3

This form outlines the patient’s financial obligations for services provided by the practice. It specifies an initial sleep apnea evaluation fee ($250.00), responsibility for co-payments at the time of service, authorization for insurance billing, and acknowledgement that the patient will be responsible for remaining balances (up to $175.00) if insurance denies, partially covers, or doesn’t respond within 60 days. It also includes an authorization to charge a credit card for any remaining patient responsibility.