Please answer the next questions to the best of your ability.

If possible, please have your spouse, partner, roommate, or family member complete the next question.

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 haven’t 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 

It is important that you answer each question as best you can.

We are committed to serving you with compassion, care, skill, and respect. Sleep solutions of North Florida does not discriminate on the basis of sex, age, creed, race, or national origin. As one of our patients, you have choices, rights and responsibilities.

You have the RIGHT:

To be treated with dignity and respect
To know the names and professional status of people serving you
To privacy
To confidentiality of your records
To receive accurate information about your health related concerns
To know the effectiveness, possible side effects and problems of all forms of treatment
To participate in choosing a form of treatment
To receive education and counseling
To consent to, or refuse, any care or treatment
To select and/or change your health care provider
To review your medical records with a clinician
To file a concern or grievance
To fair and humane treatment
To information about services and any related costs
To self-determination; including the right to make choices about life- sustaining treatment

You also have the RESPONSIBILITY:

To seek medical attention promptly
To be honest about your medical history
To ask about anything you do not understand
To follow health advice and medical instuctions
To report any significant changes in symptoms or failure to improve
To respect sleep clinic policies
To keep appointments or cancel in advanced
To seek non-emergency care during regular business hours
To report a complaint regarding the services you receive, please call the Agency for Health Care Administration toll-free (1-888-962-2873)

By signing below, you are acknowledging you have read your rights and responsibilities as a patient of Slepe Solutions of North Florida.

 

As part of the diagnostic sleep study, video surveillance of the patient’s bedroom is required at all times due to safety protocol as well as legal reasons. Data collected will only be used in the event a medical or legal issue should arise. Your information will be kept strictly confidential.

I hereby authorize the use or disclosure of any individually identifiable health information as described below. I understand that the information I authorize a person or entity to receive may be no longer protected by federal privacy regulations.

1. Specific description of information that may be used/disclosed:
MEDICAL RECORDS

2. Persons/organizations authorized to use or disclose the information:
SLEEP SOLUTIONS OF NORTH FLORIDA, LLC.

3. Persons/organizations authorized to receive the information:
REFERRING PHYSICIAN/ORGANIZATION

4. The information will only be used/disclosed for the following purpose(s):
CONTINUANCE OF CARE

5. If the purpose of this authorization is to disclose health information to another party based on health care that is provided solely to obtain such information, and I refuse to sign this authorization, the facility reserves the right to deny health care.

6. I understand that I may inspect or copy the information used or disclosed.

7. I understand that I may revoke authorization at any time by notifying the facility in writing, except to the extent that action has been taken in reliance on the authorization.

8. I understand I have the right to request/receive a Notice of Privacy Practices from the facility

I authorize payment of medical benefits to Sleep Solutions for any services furnished. I understand that I am financially responsible for any amount not covered by my insurance carrier. I authorize you to release to my insurance company or its agent information concerning health care, advice, treatment or supplies provided to me. This information will be used for the purpose of evaluating and administering claims or benefits.

I authorize my report information to be released to the medical equipment company or sleep specialist of my referring physicians choice for continuance of care in the sleep process. I have been given the opportunity to ask questions regarding my diagnosis, treatment, the procedures used, and any alternatives, if any.

I also authorize the interdisciplinary team to perform the treatments or procedures approved by my referring physician. I acknowledge and fully understand that no guarantees, either expressed or implied, have been made to me regarding my diagnosis, treatment, the procedures used, and alternatives available, if any.

We will bill your insurance company for the chargers of any procedure and you will be responsible for any difference in payment coverage. Many times insurance companies do not give us accurate coverage information and a credit card may be required to be kept on file for payment of any fees not covered by your insurance company.

Sleep Solutions of North Florida Privacy Policies:

Reason for privacy policy:

It is our desire to communicate to you that we follow the federal Health Insurance Portability and Accountability Act (HIPPA) Laws written to protect the confidentiality of your health information. The changes in the evolution of computer technology that is used in healthcare has prompted the government to seek a way to standardize and protect the electronic exchange of health information. Sleep Solutions of North Florida, LLC respects your privacy, understanding that your personal health information is sensitive. We will not disclose your information unless you tell us to do so, or unless the law authorizes or requires us to do so. HIPPA protects the privacy of the health information we create and obtain in providing our care and services to you.

For example, your protected health information includes our test results, diagnosis, treatment, health information from other providers, and billing/payment information related to the services. Federal and state laws allow us to use and disclose your protected health information for purposed of treatments and health care operations. State law requires us to get authorization to disclose this information for payment purposes.

Notice of Privacy Practices:

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

Examples of use and disclosure of protected health information of treatment, payment, and health operations:

For treatment: Information obtained by Sleep Solutions of North Florida, LLC or members of our health care team will be recorded In your medical records and may be used to help decide what care is right for you. We may also provide information to others providing you care. This helps by staying informed about your healthcare.

For Payment: When we request payments from your health insurance plan, they need information about your care. Information provided may include but it is not limited to diagnosis, procedures performed, and recommended care.

For Health Care Operations:

We may use and disclose medical records to review qualifications or performance of our healthcare providers, and to train our staff.

We may contact you by telephone, letters, or email to remind you about appointments and give you information about treatment alternatives or other health related benefits/services.

We may use and disclose information to conduct or arrange services, including: accounting, legal, risk management, and insurance services.

Your Health Information Rights:

The health and billing records we create and store are property of the Sleep Center. The protected information in it however, generally belongs to you.

You have the right to:

Receive, read, and ask questions about this notice.

Ask us to restrict certain uses and disclosures. You much deliver this request in writing to us. We are not required to grant this request, but we will comply with any requests granted.

Request and receive a paper copy of the most current Notice of Privacy Practice for protected Health information.

Request that you be allowed to see and get a copy of your protected health information. You may make this request in writing.

Have us review a denial of access to your health information-except in certain circumstances.

Ask us to change your insurance information/ You may give us this request in writing or with a phone call.

You may write a statement if disagreement if your request is denied. It will be stored in your medical record and included with any release of your records.

If you request information, we will give you a list of disclosures of your health information. The list will not include disclosure to third party payers. You may request this separately.

Our Responsibilities:

We are required to:
Keep your protected health information private.
Give you this notice.
Follow the terms of this notice.

If you believe that your privacy rights have been violated, want more information, or want to report a problem you may discuss your concerns with any staff member. You may also deliver a written complaint to the Office Coordinator at our office. You may also file a complaint to the U.S. Secretary of Health and Human Services. If you complain, we will not retaliate against you.

Other disclosure and uses of the protected health information and healthcare operations include:

Notification of family members and others:

If you request, we may release information about you to a friend/family member who is involved in your sleep disorders treatment.

In case of emergency, we may tell your family or friend your condition, and that you are in the hospital.

We may disclose health information about you to assist in disaster relief if necessary. You have the right to object to this use, or disclosure of your information.

Ask that your health information be given to you by other means or at another location. Please give us a request in writing with a signature and a date.

Cancel prior authorization to use or disclose health information by giving us written revocations. Your revocation does not affect information that has already been released or affect any action taken prior to revocation. Sometimes, you cannot cancel an authorization if its purpose was to obtain insurance.

We may use and disclose your protected health information without your authorization as follows:

For public and safety purposes as allowed or required by law: To prevent or reduce a serious immediate threat to the health or safety of a person or the public. To prevent or control disease, injury or disability.

With medical researchers: If the research has been approved and has policies to protect the privacy of your health, we may also share information.

To the Food and Drug Administration: Relating problems dealing with food, supplements, or products. To report suspected abuse or neglect to public authorities.

For law enforcement purposes: Such as when we receive a subpoena, court order, legal process, or you are the victim of a crime.

For Disaster relief purposes: For example, we may share health information with the department of health. Other uses and disclosures of protected health information not in the notice will be made only as allowed or required by law or with your written authorization.