SNOOZZEN POLICIES & PROCEDURES
- Appointment Scheduling: Please arrive on time for your appointment. If you need to reschedule, kindly provide at least 24 hours' notice.
- Cancellation Policy: Cancellations made less than 24 hours in advance may incur a full charge fee.
- Payment Methods: We accept various payment methods, including credit/debit cards and cash. Insurance claims can be processed as per your provider's guidelines.
- Privacy and Confidentiality: We prioritize your privacy and ensure that all personal information is kept confidential in accordance with relevant laws.
- Health and Safety: Please inform us of any medical conditions or allergies prior to your appointment. We adhere to strict health and safety protocols.
- No-Show Policy: Patients who fail to attend their scheduled appointments without prior notice may be subject to a full charge fee.
- Children and Accompanied Guests: For your convenience, please make arrangements for children and additional guests prior to your visit, as space may be limited.
- Feedback and Concerns: Your feedback is important to us. If you have any concerns, please address them with our staff.
SNOOZZEN – Direct Billing Consent Form
1. Authorization for Direct Billing
I authorize SNOOZZEN to:
• Submit insurance claims and necessary documentation to my insurance provider(s)
• Communicate with my insurance company regarding billing, claims, and coverage
• Receive payments directly from my insurance company for eligible services
• Submit insurance claims and necessary documentation to my insurance provider(s)
• Communicate with my insurance company regarding billing, claims, and coverage
• Receive payments directly from my insurance company for eligible services
2. Your Responsibility
• My insurance may not cover all costs
• I am responsible for any unpaid balance (deductibles, co-pays, co-insurance, denied amounts)
• Payment of any remaining balance is required upon notice
• Cancellations or no-shows without notice may result in full charges for the scheduled service
• I am responsible for any unpaid balance (deductibles, co-pays, co-insurance, denied amounts)
• Payment of any remaining balance is required upon notice
• Cancellations or no-shows without notice may result in full charges for the scheduled service
3. Insurance Information
I agree to provide accurate, complete, and current insurance information required for direct billing, including:
• ☐ Photos of insurance cards
• ☐ Policy numbers
• ☐ Subscriber names and birthdates
I also consent to providing insurance information for family members or relatives who wish to receive services at SNOOZZEN and agree to direct billing, provided they have given their informed consent:
• ☐ I am providing information for family members/relatives
• ☐ Photos of insurance cards
• ☐ Policy numbers
• ☐ Subscriber names and birthdates
I also consent to providing insurance information for family members or relatives who wish to receive services at SNOOZZEN and agree to direct billing, provided they have given their informed consent:
• ☐ I am providing information for family members/relatives
4. Privacy and Confidentiality (Alberta PIPA)
I understand that:
• My personal and insurance information is collected, used, and disclosed only to provide services and process insurance claims
• SNOOZZEN follows Alberta’s Personal Information Protection Act (PIPA)
• My information will be kept confidential and secure, except where disclosure is required for insurance processing or by law
• My personal and insurance information is collected, used, and disclosed only to provide services and process insurance claims
• SNOOZZEN follows Alberta’s Personal Information Protection Act (PIPA)
• My information will be kept confidential and secure, except where disclosure is required for insurance processing or by law
5. Easy Consent Method (One-Step)
To start my insurance claims and book my appointment online, I understand that I can:
• Send my insurance information via text or email (photos of insurance card(s), policy numbers, and birthdates)
• By sending this information, I confirm that I have read and agree to the Consent Agreement for Direct Billing, authorize SNOOZZEN to submit claims on my behalf, and accept responsibility for any balance not covered by my insurance provider
• ☐ Optional: I am including insurance information for family members or relatives who consent
Sending insurance information acts as my electronic signature and consent
• Send my insurance information via text or email (photos of insurance card(s), policy numbers, and birthdates)
• By sending this information, I confirm that I have read and agree to the Consent Agreement for Direct Billing, authorize SNOOZZEN to submit claims on my behalf, and accept responsibility for any balance not covered by my insurance provider
• ☐ Optional: I am including insurance information for family members or relatives who consent
Sending insurance information acts as my electronic signature and consent
6. Cancellation of Consent
• This consent remains valid until I cancel it
• To cancel, I must submit a written request by email to: [email protected]
• Cancellation applies only to future services and does not affect claims already submitted
• To cancel, I must submit a written request by email to: [email protected]
• Cancellation applies only to future services and does not affect claims already submitted
7. Acknowledgment and Signature
By signing below, I confirm that I have read, understood, and agree to the terms of this Consent Agreement.
Client Full Name (Printed / Electronic Signature): __________________________
Date: __________________________
Client Full Name (Printed / Electronic Signature): __________________________
Date: __________________________
Note: Sending your insurance information via text/email counts as electronic consent and carries the same legal effect as a handwritten signature.
