Recipient Acknowlegement for the Notice of Privacy Pracitices:
I have been made aware of the Privacy Practices for NeoSleep, LLC. I understand that this notice states how NeoSleep may use and disclose my Protected Health Information, (PHI).
Consent for Treatment:
I authorize NeoSleep, LLC to perform all exams, telehealth visits, procedures, equipment monitoring and other care deemed necessary or advisable for the diagnosis and treatment of my medical condition(s).
Right to Refuse Treatment:
I understand that I also have the right to refuse care, treatment or services.
Consent for Release and Acquisition of Medical Records:
In order to assure that I am receiving the highest quality of care, I give permission for NeoSleep, LLC to obtain any and all of my medical records. In order for NeoSleep, LLC to obtain and release my records in a timely manner, I authorize NeoSleep, LLC to convey my records by certified mail, courier or electronic transmission.
Recording, Filming and Other Images:
I voluntarily agree to recording, filming or other images for the purposes fof identification, diagnosis and treatment which will be incorporated into my medical record.
Financial Agreement:
I understand that I am responsible to pay NeoSleep, LLC for services rendered. I have received the notice of Patient Financial Responsibility and am in agreement with the polices therein.