Managed Care Payment Form

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- NOTICE OF PATIENT FINANCIAL RESPONSIBILITY
  
  Thank you for allowing SomnoMed to be your Oral Appliance provider. We are committed to providing you with the highest quality products and services for the treatment of Obstructive Sleep Apnea (OSA).
  
  SomnoMed provides products and services in good faith, and it is important that you understand your medical insurance plan and its current benefits and coverage. Policies and coverage determinations may vary from year to year, so if you have questions, please contact your health plan administrator. Your SomnoMed oral device is billed under your medical insurance (not dental) as Durable Medical Equipment (DME) under treatment code E0486.
  
  Patient Financial Responsibilities
  - As the patient, you are responsible for the payment of your treatment.
  - SomnoMed will bill your insurance company. However, you are required to provide us with the correct and most updated information about your insurance plan. You are responsible for any charges incurred for incorrect or outdated information provided. Keep in mind that the co-insurance quoted to you at the time of connection is only an estimate and you are responsible for any additional amounts owed. Overpayments will be paid back to you once your account has been settled with your insurance company.
  - You are responsible for paying your co-pays, co-insurance, deductibles, and any add-on costs not covered by your insurance plan (i.e. compliance recorder, edentulous devices).
  - Co-pays and deductibles are non-refundable after IOS scans or impressions and/or models have been completed by the sleep dentist, except if a SomnoMed device is deemed not clinically suitable by your sleep dentist during your initial evaluation.
  - You are responsible for the payment of additional charges at the discretion of SomnoMed. These charges may include (but are not limited to) a returned check, credit card payments, and any other penalties and collection costs incurred.
  - If you request a change in your selected DDS once impressions or IOS scans have been taken, or if the device has been manufactured and/or delivered to you, you will be responsible for any additional cost resulting from the change.
  - If you have questions or concerns you can contact a SomnoMed Patient Care Coordinator at 866.717.5337, option 6.
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- I have read and agree to the Terms of Service
Acknowledgment of Charges and Payment Terms
By agreeing to the Terms of Service, the client acknowledges and accepts responsibility for all applicable charges incurred. Payment is due as outlined in the agreement, and disputes regarding charges must be raised within 3 days of payment. Failure to dispute charges within this timeframe constitutes acceptance of the charges in full.

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Managed Care Payment Form

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NOTICE OF PATIENT FINANCIAL RESPONSIBILITY

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