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  • Patient Demographics

  • Patient Information

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  • Spouse/Significant Other

  • PRIVACY NOTICE ACKNOWLEDGEMENT OF RECEIPT

  • I have reviewed or received a copy of DSM Sleep Specialists PLC Privacy Practices Notice.

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  • This acknowledgement will be retained in the patient chart as a HIPAA record at DSM Sleep Specialists PLC.

  • Insurance

    If patient is not the policy holder, we MUST have the policy holder’s Date of Birth and Social Security Number.

  • Payor Questionnaire

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  • I herby authorize the release of necessary medical information to insurance to process my claims. I herby assign to the provider all payments for services rendered. The patient is responsible for all fees, regardless of insurance coverage. It is customary to pay for services when rendered unless other arrangements have been made. I UNDERSTAND THAT I AM PERSONALLY RESPONSIBLE FOR THE AMOUNT OF PATIENT LIABILITY AND/OR SERVICES NOT COVERED BY INSURANCE. CO-INSURANCE AND CO-PAYS ARE DUE AT THE TIME OF SERVICE.

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