TeleVisit & Other Payments - Sneeze & Snooze Clinic

Patient Name*

First Last

Date of Birth*

Billing Address*

Street Address Address Line 2 City State ZIP Code

Email*

Phone*

Payment Options (as of 03/02/2021)*

New Patient (Self Pay) $169.99
Follow Up Visit (Self Pay) $99.00
Home Sleep Test (Self Pay) $299.00
Insurance Co-Pay
Other Amount

Please select your payment option. If you are paying using insurance, please fill out the Insurance Company, Group Number and Co-payment Amount fields. If you are paying another amount please fill out the Other Amount field.

Co-Payment Amount

Other Amount

Total

$0.00

Notes

Credit Card*

Card Details

Cardholder Name

Insurance Provider

Insurance Group Number

Insurance Card Images

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 64 MB, Max. files: 2.

Please upload pictures of the front and back of your insurance card.

Phone

This field is for validation purposes and should be left unchanged.

TeleVisit & Other Payment Options

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