If possible, please have your spouse, partner, roommate, or family member complete the next question. Or answer the next questions to the best of your ability. 

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

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)

 

Effective May 1, 2022, we now require a credit card to be on file with our office for every patient. 
 

Please understand that as health care providers our relationship is with you. Your insurance policy is a contract between you and your insurance company; we are not a party in that contract. Although we are in-network with several insurance companies, it is your responsibility to make sure that your policy will cover the services you receive at our office. If our office is not a participating provider for your plan, you may still select our office for your medical care, and "out of network" benefits will apply (if your plan has them). It is your responsibility to know your insurance benefits. Please contact your insurance company at the customer service number printed on your insurance card if you have questions pertaining to your coverage. 

As we have done in the past, we will continue to bill your insurance and you will then get a statement for the portion that your insurance determined is the patient's responsibility. If the balance is not paid within 30 days from the date of the first statement, we will then bill the credit card on file. A receipt will be available upon request. In order to be seen for another appointment, you must pay any outstanding balances in full (even if within 30 days from the date of the first statement). If you receive a statement that you feel is incorrect, please contact us immediately so we can look into whether our office or your insurance company made an error. If an error was made by your insurance company, we will ask you to contact them to resolve the issue. 

Expiration Date: One (1) year from your Date of Service.

I agree to allow Sleep Solutions of North Florida to keep my credit card on file and to charge my credit card for any outstanding balance on my patient account. This includes co-pays, deductibles, co-insurance, non-covered services, late fees, unreturned equipment, and cancellation fees. I acknowledge that:

 - My credit card will be charged 30 days after the first statement is sent following review of the final explanation of benefits from each applicable insurance company for services provided while this agreement is in effect

- If my credit card is declined, Sleep Solutions of North Florida will bill me directly for any outstanding balance. I acknowledge that I will not be able to schedule any future appointments with Sleep Solutions of North Florida until the balance has been paid in full. If the balance is not paid, I understand that my account may be sent to a collections agency and that I and my family members may be discharged from the practice. 

- I am responsible for informing Sleep Solutions of North Florida of any updates regarding my insurance or credit card information. 

 - I may request a receipt detailing the amount charged.

- I may cancel this agreement at any time by contacting Sleep Solutions of North Florida; any unpaid amounts relating to service provided while this agreement is in effect will then be billed to me directly. 

 

*Adding your card on file will not create a charge on your card

**We require a card on file for every patient even if you do not owe a copay

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.

As a patient of Sleep Solutions of North Florida, you consent to receive text messages regarding; appointment scheduling, appointment reminders, documentation requests, statement and billing delivery, and follow-up. You can opt out of receiving our text messages at any time by making the appropriate reply to those text messages. If a mobile number is not available, then text messages will not be sent. Message and data fees may apply. 

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 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.

This authorization allows Sleep Solutions of North Florida to use and disclose (release) certain PHI, which includes medical records, as I have directed. I understand that: 

- The PHI may include information about mental health, substance and/or alcohol abuse, HIV/AIDS, andSTDs.

- This authorization may be used to share the same type of PHI indicated above which may be created inthe future, until the expiration date.

- This authorization will remain in effect until the date specified above or, if no date is specified, until Irevoke it in writing.

- I have the right to revoke this authorization at any time, if I do so in writing to Sleep Solutions of NorthFlorida and that the revocation will not apply to action already taken as a result of this authorization.

- I may refuse to sign this authorization and doing so will not affect my treatment, payment, enrollment, oreligibility for benefits or the quality of care that I will receive.

- PHI released per this authorization may no longer be protected by state law or the federal health privacylaw and could be redisclosed by the person or entity that receives it.