Home Sleep Testing

 

Release and Consent


  1. ASSIGNMENT OF BENEFITS / Financial Responsibility
    I request that the payment of authorized Medicare, Medicaid and/or other third-party insurance benefits, including supplemental, co-insurance or Medigap policies be made on my behalf directly to Sleep Management Solutions (SMS) for the provision of Home Sleep Testing under this Agreement. I agree to provide all documents and information necessary for SMS to obtain direct payment from Medicare, Medicaid or other third-party payers. I hereby authorize the release of my medical information to the Centers for Medicare and Medicaid Services, other third-party insurers and their agents respectively, to determine benefits payable under Medicare and/or other third-party insurers with respect to the Home Sleep Testing performed. I understand my financial responsibility as explained and provided to me in writing by SMS.
  2. RELEASE OF INFORMATION
    I consent to the release of information by my Physician, Licensed Health Care Professional, or Facility, and to allow the disclosure of medical records to SMS. I consent to the release of information by SMS to their representative of other health providers involved in my care and to third party payers in order to assure continuity of treatment; proper communication of information to my physician(s) and referral source; and proper reimbursement of services.
  3. AGREEMENT
    This Agreement is made by and between SMS and myself. SMS shall provide me with a Home Sleep Testing Device subject to the terms of this Agreement. I understand and acknowledge that: 1) I am under the supervision and control of my physician; 2) My physician has prescribed the Home Sleep Study as part of my plan of care; 3) SMS's services do not include diagnosing, prescriptive or other functions performed by licensed physicians; 4) My physician is solely responsible for diagnosing and prescribing drugs, equipment and therapy for my condition and otherwise supervising and controlling my medical condition; 5) I understand my Rights and Responsibilities as provided to me by SMS; and 6) I have been provided SMSís Notice of Privacy Practices.
  4. CONSENT FOR HOME SLEEP TESTING
    I consent for SMS to send to me a Home Sleep Testing Device authorized by my physician. I understand that this test has been ordered by my physician. I acknowledge that the proper administration of this test will be provided by SMS prior to my taking the test. The proper administration of my home sleep study will have been explained to me by SMS and I will receive adequate written and visual educational materials to properly administer the test. I understand that I have available to me a qualified sleep technician to assist me with any questions I may have regarding the administration of this test. I am aware that this technician is available to me 24 hours per day, 7 days per week.
 

Device Return Agreement


I hereby understand and agree that the Home Sleep Testing equipment provided by Sleep Management Solutions (SMS) is a very expensive piece of technology (priced at $5000) and is being provided to me as a rental device. I acknowledge that I am expected to take my sleep test and return the device to SMS no later than seven (7) days after the receipt of the device. If I fail to return the device within this period of time, SMS will have the right to bill me directly for the cost of the equipment.

I acknowledge that I understand the importance of taking this prescribed test in order to effectively diagnose and treat my suspected Sleep Disorder. I also agree to communicate with the SMS sleep technicians by calling 888-497-5337 the day after taking the test to answer a few brief questions. I also understand that I have 24/7 access to a sleep technician at the above number to answer any questions I might have concerning the taking of the home sleep test.