HSD Agreements (NightOwl)

Please allow this letter to acknowledge that we shall hold the signer below financially responsible for the shipped goods listed below. The terms for use are:

1. The aggregate cost/value of the goods subject to use shall not exceed Sixty Five Dollars ($65).

2. The unit below must be used with in 7 days from the day USPS shows delivery. You understand if you decide to NOT to use the device with in that 7 day timeframe there will be a $65 service fee applied to your credit card on file.

3. All required documents must be signed before a device can be shipped to a patient.

4. I have been educated to use the equipment and have been given directions. If I have addition questions I will call (714)-427-5900 for assistance.

Thank you for your cooperation in this matter.

Equipment Description: NightOwl

0 - Never    1 - Slight Chance    2 - Moderate    3 - Always

0 - Never    1 - Slight Chance    2 - Moderate    3 - Always

I authorize Home Sleep Diagnostics to bill my insurance and receive payment directly for services provided. I authorize the release of any medical or billing information necessary to process claims, obtain payment, or determine benefits. A copy of this authorization is as valid as the original.

Submitting claims is a courtesy and does not guarantee payment. I understand that I am financially responsible for all amounts not paid by my insurance, including deductibles, copayments, coinsurance, non-covered services, denied claims, and any charges resulting from inaccurate or incomplete insurance information. I authorize Home Sleep Diagnostics to charge any approved payment method on file for my patient responsibility after insurance has processed my claim.

Insurance coverage and payment are determined solely by my health plan. Home Sleep Diagnostics does not guarantee insurance coverage or payment.

Medicare Patients Only

If Medicare determines that a service is not reasonable and necessary or otherwise denies coverage, I understand that I may be financially responsible for those charges. When required by Medicare, I will be asked to sign a separate Advance Beneficiary Notice (ABN) before services are provided.

By signing below, I acknowledge that I have read, understand, and agree to these terms.

If signed by caregiver or other, please list relationship (i.e. Husband, Wife, R.N., etc.) 

Accepted

The Health Insurance Portability & Accountability Act of 1996 (HIPAA), a federal program, requires we maintain the privacy of your health information and all medical records used or disclosed by us in any form. HIPAA provides penalties for entities misusing personal health information.

HIPAA dictates we may use and disclose your medical records only for the following purposes.

Treatment - provides, coordinate, or manage health care and related services by one or more health care providers.

Payment - obtain reimbursement for services, confirm coverage, bill or collect charges, and for utilization review.

Health care operations - business aspects of running the practice, i.e.: conduct quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service.

We may also create and distribute health information by removing all references to the patient’s identity.

We may contact you to schedule appointments or provide information about benefits and services that may be of interest to you. If we cannot reach you personally we may leave a message on your answering device (answering machine, cell phone, etc.) or another person who answers your phone.

Other uses and disclosures will be made only with your written authorization, which you may revoke in writing. We will honor and abide by that written request, except for information previously released on your authorization.

You have the following rights with respect to your protected health information, which you may request in writing.

1. The right to request restriction on certain uses and disclosures of protected health information, including disclosures to family members, other relatives, close personal friends, or any other person identifies by you.  We will honor the restriction until you withdraw it in writing. In certain emergency circumstances we may not be required to honor the restriction.
2. The right to reasonable  requests to receive confidential communications  of protected health information from us by alternative means or at alternative locations.
3. The right to inspect and copy your protected health information.
4. The right to amend your protected health information.
5. The right to receive an account of disclosures of protected health information.

This Notice of Privacy Practices is effective August 1, 2004. We reserve the right to change the terms of our Privacy Practices and to make the new terms effective for all protected health information we maintain. We will post and you may request a written copy of a revised Notice from this office.

If you feel your privacy protections have been violated, you have the right to file a written complaint with our office, or with the agency noted below. We will not retaliate against you for filing a complaint.

For more information: