ASSIGNMENT OF BENEFITS: I hearby assign all medical and/or surgical benefits to which I am entitled including major medical, Medicare, Private Insurance and any other health plan to The Dallas Center for Sleep Disorders. This agreement will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by insurance and I hearby authorize said assignee to release all information necessary to secure payment.

• The patient is responsible to pay any deductible and co-payments prior to or at the time services are rendered.
• It is your responsibility to know if a referral is necessary for your visit.
• Any portion of a billed amount that is labeled “not allowed” or “not covered” will be the patient’s responsibility. This is not the contractual obligation amount the physician will discount due to the practice’s relationship with your insurance plan.
• Our office NEVER guarantees that your insurance will pay, or that they will pay what they quoted our benefits team. We will make every attempt at the beginning of your health care to receive verification of your policy benefits. However, if for some reason your insurance claim is denied, you are responsible for the amount due on your account.
• If your insurance has not processed and paid your claim within 6 months, you will be responsible for the balance on your account.
• Your insurance is a contract between you and the insurance company. We are not party to that contract. While we have an agreement with the Plan to provide services, any questions regarding coverage must be resolved by you with your insurance company.

For patients requesting forms to be completed/signed or letters to be written on their behalf:

There is a $50 fee for any forms or letters.  This fee applies to each form or letter requested.  

It is the patient’s responsibility to inform Dallas Sleep of any form or letter request at the time of scheduling.  Forms and letters typically take 4-5 business days to complete.  You may also be required to complete a sleep study before your form or letter is completed.  Please plan accordingly.  

Dallas Sleep reserves the right to make a final decision on whether we are comfortable completing any forms or letters until after your appointment with one of our Providers.  Having an appointment does not guarantee that we will sign your form or letter.  

Any forms requested for completion/signature must be presented at the time of check in.  

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

This notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment of health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

1. Uses and Disclosures of Protected Health Information

Your protected health infor mation (PHI) may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your healthcare with any related health services. This includes the coordination or management of your health care with a third party. For example, we would disclose your PHI as necessary, to a durable medical equipment company that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment: Your PHI will be used, as needed, to obtain payment for your health care services; For example, obtaining approval for an overnight sleep study may require that your relevant protected health information be disclosed to obtain approval or authorization.

Healthcare Operations: We may use or disclose, as needed, your PHI in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, licensing or conducting or arranging for other business activities. In addition, we may use a sign in sheet at the registration desk where you will be asked o sign your name. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment.

We may use or disclose your PHI in the following situations without your authorization. These situations include, as required by law, public health issues as required by law, communicable diseases, abuse or neglect, FDA requirements, legal proceedings, law enforcements, coroners, criminal activities, military activities and national security, and worker’s compensation. Under the law, we must make disclosures to your and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of section 164.500.

Other permitted and required uses and disclosures will be made only with your consent, authorization or opportunity to object unless required by law.

You may revoke the authorization at any time, in writing, except to the extent that your physician’s practice has taken an action in reliance on the use of disclosure indicated in the authorization.

This Release of Information will remain in effect until terminated by me in writing.

Scheduled appointment times are reserved especially for you. If an appointment is missed or cancelled with less than 24 hours notice for office appointments and Sleep Studies, you will be billed:

$100 for new patient appointments

$35 for clinic appointments

$250 for Sleep Study appointments

Please note that calls must be received during our regular business hours. Our hours are Monday – Friday, from 8 am to 5 pm.

Please know that your insurance company does not cover this charge. Repeated “no show” appointments could result in referring you back to your insurance company for reassignment to another specialist.

I understand that the office will make every attempt to place a reminder call for my appointments. However, whether or not a confirmation call is placed, I am still held responsible for remembering my appointment day and time.

Select any that apply below:

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation:

0 – Would never doze | 1 – Slight chance of dozing
2 – Moderate chance of dozing | 3 – High chance of dozing

The Dallas Kakar Inventory is a screening tool and is not intended to provide a diagnosis of any disease or illness. The Author of the Inventory assumes no liability for its use.

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Dallas Sleep

6313 Preston Road, Suite 400 | Plano, Texas 75024
T 972.473.7300 | F 972.473.7750