Starlight Logo

Patient Financial Responsibility & Billing Consent

Last Updated: February 27, 2026

This informed consent applies to patients of:

  • Marley Medical Provider Group, P.A., dba Starlight Provider Group, PC, a Florida professional services association
  • Starlight Provider Group NJ, P.C., New Jersey professional services corporation

Each Provider Group listed above is individually a “Practice”.

1) Insurance & Assignment of Benefits

  • I authorize the Practice and/or its agents to bill my insurance plan(s) and to release information about me in its possession to my Plan, the Social Security Administration, any state administrative agency, or their intermediaries or fiscal agents required or requested in connection with any claim for services rendered to me by Provider, for payment, care coordination, and healthcare operations.
  • I acknowledge and agree that I am responsible for all charges for services provided to me which are not covered by my Plan or for which I am responsible for payment under my Plan. To the extent no coverage exists under my Plan, I acknowledge that I am responsible for all charges for services provided and agree to pay all charges not covered by my Plan. I understand I am responsible for all amounts my plan assigns to me, including copays, coinsurance, deductibles, and any non-covered/out-of-network charges under my plan.
  • I irrevocably assign to the Practice and Providers who treat me (collectively, “Provider”), all of my rights and benefits and any other interests that I have in any medical insurance plan, health benefit plan, indemnity plan, trust, fund or other source of payment for healthcare services (each a “Plan”) in connection with medical services provided by Practice, its employees and agents. I understand that this document is a direct assignment of my rights and benefits under my Plan. I instruct my insurance company to pay Practice directly for the professional or medical expense benefits payable to me. ‍In addition, I agree and understand that any funds I receive by my insurance company due for services rendered by Practice will be immediately signed over and sent directly to Practice.
  • If my plan pays me directly for services rendered by the Practice, I agree to endorse/forward those payments to the Practice within 10 days.
  • I agree to provide accurate and current insurance information and to notify the Practice of changes before my visit. If my coverage is inactive or cannot be verified, I may be treated as self-pay and receive a GFE.

How Copays, Deductibles, and Coinsurance are collected:

  • Copays (when required by my plan) are due at the time of service. If not collected at check-in, I authorize the practice to invoice me.
  • Deductibles & coinsurance are usually determined after my insurer processes the claim. I will receive a statement and 5–7 business days’ notice when any amounts are due.
  • If the plan later adjusts the claim (additional payment or reversal), the Practice will issue a refund or corrected balance.
  • If a service is denied or not covered under my plan (e.g., benefit limits, policy exclusions, out-of-network), I am responsible for the charges unless prohibited by law or plan contract. The Practice may assist with an appeal when appropriate.

2) Self-Pay & Good Faith Estimate (GFE)

  • I have federal rights under the No Surprises Act. If I am uninsured or choose to self-pay, I will receive a Good Faith Estimate of expected charges before my visit (or upon request). The GFE is not a bill and may list ranges for common services.
  • If my final bill is substantially higher than my GFE, I may use a federal dispute resolution process.
  • If I have insurance, I can request an estimate from the Practice.
  • ‍In the event I have selected services for purchase from Practice on a self-pay basis, I am directing Practice to treat my purchase of these services as if I am an uninsured patient and I agree to be 100% responsible for full payment of the listed price of the services.  If, though I have selected our “self-pay” option, I intend to submit a claim to my insurance company, I understand that my insurance policy is a contract between me and my insurance company. It is my responsibility to know my benefits, and how they will apply to my benefit payments, and Practice assumes no responsibility to understand or be bound by the terms and conditions of such insurance. By electing to receive services on a self-pay basis, I am electing to purchase services that may or may not be covered by my insurance if I obtained those services from a different provider. I understand there is no guarantee my insurance company will make any payment on the cost of the services I have purchased.

3) Location Confirmation

  • I will truthfully confirm my physical location at the time of each telehealth session. I understand services can only be provided while I am physically in a state where my clinician is licensed.
  • I understand telehealth visits may be billed the same as in-person visits, but coverage varies by plan.

4) Card-on-File (COF) Authorization

  • I authorize the Practice to securely store my payment method using tokenization. The Practice does not store my card’s CVV/CVC.
  • After my insurer processes the claim, I will receive a statement showing what I owe and a charge date at least 5–7 business days later. On that date, the Practice may charge my stored payment method for the patient responsibility amount shown.
  • I can update or revoke this authorization anytime before a charge is processed by contacting the Practice.

5) Financial Assistance (FA)

  • I may apply for need-based discounts under the Practice’s written FA policy. Discounts are not routine copay waivers and may be limited by my insurance contract and applicable law.

6) Non-Covered/Elective Services

  • If a service is not covered or requires special approval, I may be asked to sign an acknowledgment before receiving that service and may be responsible for payment.

7) Refunds & Credits

  • If applicable, overpayments will be refunded within 30 days.

8) Communications & Electronic Delivery

  • I agree to receive estimates, statements, and notices electronically (email, portal, or text) unless I opt out. By providing my phone number I consent to receive communications from Practice or its affiliates via text message. I will keep my contact information current.
  • Electronic signatures and acknowledgments provided by me to the Practice are legally valid.

9) Questions & Disputes

  • For billing questions or to request FA or a payment plan, you can email us at  support@hellostarlight.com, or by phone at (888) 828-1871 or by mail at 2332 Galiano Street 2nd Floor, Coral Gables, FL 33134.
  • Uninsured/self-pay patients may also use the federal dispute process if final charges are substantially higher than the GFE.