Consent for use and Disclosure of Health Information
Purpose of consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activites, and healthcare operations.
Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this consent. Our notice provides a description of our treatment, payment activites and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our notice is available upon request.
We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices. These changes may apply to any of your protected health information that we maintain.
You may obtain a copy of your Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting our office.
Right to Revoke
You have the right to revoke this consent at any time by giving us written notice of your revocation submitted to Sleep Health Partners. Please understand that revocation of this consent will not affect any action we took in reliance on this concent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this consent.
I have had full opportunity to read and consider the content of this consent form and your Notice of Privacy Practices. I understand that by signing this consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activites and health care operations.
Billing and Insurance Policy
Sleep Health Partners would like to thank you for choosing us for your care. We are commited team and strive to provide exeptional service. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our Financial Policy, which we require you to read and sign prior to any treatment.
We will verify and check benefits with your medical insurance company and inform you of your out of pocket and/or co-insurance prior to starting treatment. We send all claims to your insurance company and will assist you in getting reimbursement.
Some insurance plan will require a referral from a physician in order to obtain coverage, so you may need to contact your primary care provider and have the referral sent to our office. We recommend contacting your medical insurance company prior to treatment to confirm coverage.
If you have not had a sleep study or been diagnosed with sleep apnea we will coordinate a home sleep test and a face to face visit with a medical sleep specialist. Payment of $249 is required prior to dispensing the home sleep test device and scheduling a face to face visit with a medical sleep specialist.
Sleep medicine is a multi-disciplinary specialty, so it requires a medical sleep specialist to oversee care in addition to a dental sleep specialist to provide the oral appliance. As with any medical condition, anual follow up care is required. For that reason, we require an anual sleep test and face to face with a medical sleep specialist to review your sleep test results in addition to anual check up with Sleep Health Partners to check progress of treatment and condition of your existing oral appliance. Any transfering care to sleep health partners will need a sleep test and face to face with a medical sleep specialist within 12 months.
By signing below, you are acknowledging that you have read, understood, and agreed to follow the policy stated above.