The above information is true to the best of my knowledge. I understand that I am responsible for charges associated with medical services and agree to pay all bills within 30 days of receipt of statement, unless other arrangements are made with this office, in advance. I authorize the physicians and Anchorage Sleep Center, LLC to release any information required to process my insurance claims. I also authorize payment of insurance benefits directly to Anchorage Sleep Center, LLC.

What time on weekdays do you usually?

What time on weekends do you usually?

What are your usual work hours?(if applicable)

How long does it take you to get to sleep?

How often do you wake up at night?

How long to return to sleep?

How likely are you to doze off or fall asleep in the following situations?
0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing

Please list medical practitioner(s), spouse, caregiver(s), guardian(s), etc. you are authorizing to receive PH

The purpose of this release of protected health information authorization:
I hereby authorize the use or disclosure of my health care and/or other information within my patient record to the entities stated above. I understand that this authorization is voluntary. I understand that my records may contain sensitive information. I understand that I may revoke this authorization at any time by signing the revocation section at the bottom of this form, or by notifying Anchorage Sleep Center, LLC in writing, but if I do, it will not affect actions taken on this authorization before my revocation was received. I understand that Anchorage Sleep Center, LLC will not condition my treatment, payment, or eligibility for services based on whether I provide this authorization.
I understand that if the person(s) or entities I authorize to receive my protected health information are not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations. To the extent that this information is required to remain confidential by federal or state law, the recipients of this information must continue to keep this information confidential. I understand that I may request a copy of this signed authorization.

*A photocopy of this authorization as valid as the original

Anchorage Sleep Center, LLC offers sleep diagnostic and treatment services for patients referred to our practice. We are a licensed provider who develops individualized treatment plans to identify the services that will best suit your therapy needs. We work with your primary care practitioner to coordinate your care. Following your initial assessment visit(s), we develop a specific plan of care for review and approval by your referring provider. Once your referring provider signs your Treatment Plan, we can begin working with you to improve your health condition. We are pleased to serve your sleep needs and encourage your feedback to alert us to anything we can do to provide you the highest quality of care. We require certain information from each patient in order to begin your care. The attached forms need to be completed in order for us to get you started as our patient. Please do your best to complete all the information. If certain information does not apply to you, please indicate that by noting “N/A” (“Not Applicable”) so that we know that you did not overlook anything. Each healthcare insurance payer has different guidelines for allowing coverage of sleep services. It is helpful if you let us know your healthcare payer when starting service so that we may find out if prior authorizations are needed. If you are a Medicaid beneficiary, please ask your primary care provider to send us a referral for your initial assessment to fulfill Medicaid requirements. If your healthcare insurance payer does not cover sleep medicine services, you are welcome to make self-pay arrangements for the usual and customary pricing of our services.
PRESCRIPTIONS
We do not issue prescriptions for medications. We are glad to coordinate your care through your primary care provider who has the ability to write prescriptions for you. If you feel you would benefit from the use of prescription medications, please talk with our therapist for assistance.
NO SHOW POLICY & CANCELLATION POLICY
If you cannot make it to a scheduled appointment, please contact our office at least 24 hours in advance. A charge of $250.00 will be assessed to patient accounts for missed appointments without prior notice. This charge will not be billed to your healthcare insurance payer and is the responsibility of the patient (or parent) to pay. All cancellations and issues associated with appointments should be directed to the individual office: Anchorage 907-743-0050 / Wasilla 907-357-4200 / Fairbanks 907-374-9920 / Southeast 907-500-7368. Business hours are Monday-Friday 9:00am – 5:00pm.
WAIT LIST FOR SERVICES
If you would like to reschedule an appointment for a day or time that is not available, please let us know and we will place you on our waiting list. If another patient cancels their appointment, we will contact patients on the waiting list on a first come, first call basis.
WORKER’S COMPENSATION
If you are being treated for a work related condition, please complete our worker’s compensation verification form so that we may submit needed authorizations and claims on your behalf.
MEDICARE, MEDICAID & PRIVATE INSURANCE
CO-PAYMENTS, DEDUCTIBLES AND NON-COVERED SERVICE
Medicare has a limit on the amount of sleep services they pay for. Once you have exceeded the financial limit of your Part B benefits, and you do not have additional healthcare coverage, you are responsible for the payment of your services.
Additionally, Medicare and private healthcare insurance payers have deductible and co-payments for sleep medicine services that are the responsibility of the patient.
BLLING AGENT CONTACT INFORMATION
Our practice uses a professional billing service to process your claims to healthcare payers and to arrange payment of patient balances. We have all the required agreements in place to insure that your protected health information is safe and remains confidential. If you have inquiries about your healthcare claims, monthly statements, or if you have additional billing information, you may reach our billing agent at: Anchorage Sleep Center, LLC 907-743-0050
INTEREST CHARGES ON PATIENT BALANCES
Our practice charges interest on unpaid account balances. If we receive payment from on your account from either you or your healthcare insurance payer within 30 days, no interest charges will be applied to your account.
COLLECTION OF PAST DUE ACCOUNTS
We communicate with our patients to resolve past due accounts in all cases. If we cannot reach a patient by phone following the return of undeliverable mail, or if a patient payment agreement cannot be made or paid as agreed, we are forced to use the services of a professional collection agency. Once an account is placed with a collection agency, we cannot take the account back. Please let us know when or if your patient contact information changes so that we can always reach you, if needed, to discuss past due accounts.
FINANCIAL AGREEMENT
New patients approved for sleep services are responsible for any and all charges not paid for by healthcare insurance payers (Medicare, Medicaid, Private Health Insurance Carriers, Worker’s Compensations, etc.). By signing this patient agreement, you are acknowledging that you understand this condition of service and commit to promptly paying Anchorage Sleep Center, LLC for the services we provide to you, our valued customer. Following the receipt of your monthly patient statement, please contact our practice to make payment arrangements. We accept cash, personal checks, money orders, and credit cards VISA, MasterCard, we also make credit card pre-payment arrangements for anticipated monthly patient balances. We also are willing to make reasonable payment arrangements to keep your account current. Please contact our Billing Office at 907-743-0050.
QUALITY ASSURANCE & COMPLAINT RESOLUTION
Should you or your caregiver experience a situation that requires the attention and resolution of a Supervisor and/or Manager, please contact our practice either by phone or in writing. Our Manager/Business Owner will interact with you to reach a resolution of any identified situation where our quality of service has been compromised. We use such situations to alert us to improvements we can make to better serve all our patients.
PATIENT STATEMENT OF AGREEMENT
My signature below signifies that I have read and understand this patient agreement for Anchorage Sleep Center, LLC to provide me sleep services. I agree to the terms in this patient agreement and intend to comply with them to the best of my ability. I understand that if I fail to follow the terms of this agreement, I could be discharged from service.

Consent to Medical Treatment:
I, the undersigned, hereby consent to and permit my attending physician and his/her designees, the Sleep Center and its employees, and all other persons caring for me to provide treatment and care as may be deemed necessary and available to me during my stay in the Sleep Center including, but not limited to tests, examinations, and medical treatment. I understand that my care is under the control of my attending physicians who are independent practitioners. I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees or promises have been made to me as to the result of treatment or examination at Anchorage Sleep Center, LLC.
Authorization to Release Medical Information:
I hereby authorize Anchorage Sleep Center, LLC to disclose all or any part of my record, and any other information in the Center’s possession, to any other charges related to my care, including, but not limited to worker’s compensation carriers, insurance companies, welfare funds, or my employer. I hereby release Anchorage Sleep Center, LLC from all legal responsibility or liability, which may arise from disclosure of my record as provided in this paragraph. I hereby authorize Anchorage Sleep Center, LLC to furnish requested information excerpts from my record to any insurer, its intermediary or another health care facility to provide continuity of care. Anchorage Sleep Center may periodically participate in statistical research studies. I agree that statistical information can be released on an anonymous/confidential basis. I understand that Anchorage Sleep Center, LLC keeps a record of the health care services provided and that I may review my record (a 24 hour notification is required). I may request a copy of all or any part of my record, (there is a charge for this service), and I may ask Anchorage Sleep Center, LLC to correct that record. Except as noted above, Anchorage Sleep Center, LLC will not disclose my record unless I direct them to do so, unless the law authorizes or compels them. I may see my records or get more information about it from the main office of Anchorage Sleep Center, LLC.
Consent to Record Audio/Video:
I understand that during the course of my sleep study, I may be video/audio taped by the sleep technologist. I hereby authorize the use of this video/audio for the sole purpose of medical diagnosis and treatment. This video will not be distributed or shared for any purpose, unless requested under applicable law.
Photographs:
The taking, reproduction and use of photographs in connection with my diagnosis, care and treatment at Anchorage Sleep Center, LLC for purposes of scientific and medical study and research is approved, provided my identity is not revealed. Photographs may include the use of video tapes and television.
Authorization of Payment:
I hereby authorize payment of medical benefits directly to Anchorage Sleep Center, LLC for services rendered to me during the period of my medical/surgical care. I understand that I am financially responsible for any balance not covered by my insurance. I permit a copy of this authorization to be used in place of the original.
Medicare Authorization: (FOR MEDICARE PATIENTS ONLY)
I hereby request that payment of Medicare benefits be made either to me or on my behalf to Anchorage Sleep Center, LLC for services rendered to me by that physician, clinic or supplier. I authorize any holder of Medicare information about me to be released to the Centers for Medicare Services (CMS) and its agents, information needed to determine the benefits payable for related services. 

Acknowledgment of Receipt of HIPPA Notice
I understand Anchorage Sleep Center, LLC, the referring physicians and interpreting physicians are a part of an organized healthcare arrangement and these providers may share my health information for treatment, billing and healthcare operations. I have been given the opportunity to review a copy of the organization’s Notice of Privacy Practices that describes how my health information is used and shared. I understand that organized healthcare management arrangement has the right to change this notice at any time. My signature below constitutes my acknowledgement that I have been provided with an opportunity to receive a copy of the Notice of Privacy Practices.
Financial Agreement / Patient Responsibilities:
You have the RESPONSIBILITY to:
• Provide accurate and complete details about your illness, hospitalization, medications and present conditions.
• Tell your doctor about any change in your condition or if problems arise.
• Tell your doctor or nurse if you do not understand your treatment or what you are expected to do.
• Accept financial responsibility for payment of services, pay your bill promptly or to inform Anchorage Sleep Center, LLC if you are unable to pay your bill.
• Notify Anchorage Sleep Center, LLC of any changes in healthcare benefits.
By signing below, I certify that I have read the above information and that I understand its content, my questions have been answered to my satisfaction.

As required by privacy regulations created as a result of the Health Insurance Portability/Accountability Act of 1996, THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU MAY ACCESS THIS INFORMATION. PLEASE READ CAREFULLY. Within this document the patient is referred to as “you”. If you are a parent or legal guardian of the patient, reading this notice will inform you of the clinic’s policies regarding your child’s medical information and how it will be handled.
Commitment to Privacy:
This clinic is committed to maintaining the privacy of your protected health information (PHI). We are required by law to maintain the confidentiality of your health information. We also are required by law to provide you with this notice of our legal cuties and privacy practices that we maintain in this clinic concerning your PHI. By federal and state law, we must follow the terms of the notice of privacy practices that we have in effect.

We recognize that these laws are complicated, but we must provide you with the following important information:
• How we may use and disclose your PHI.
• Your privacy rights regarding your PHI.
• Our obligations concerning the use and disclosure regarding your PHI.
We May Use and Disclose Your Protected Health Information (PHI) in the Following Ways:
1. Treatment – This clinic may use your PHI for treatment purposes. We may disclose your PHI to other health care providers for purposes related to your treatment. This may include, but is not limited to, your doctor, other providers, caseworkers, and school related personnel.
2. Payment – This clinic may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from us. For example, we may use and disclose your PHI to obtain payment from third parties that may be responsible for such costs.
3. Health Care Operations – This clinic may use and disclose your PHI to operate our business. An example of this is, using your PHI to evaluate the quality of care you receive from us.
4. Appointment – This clinic may use and disclose your PHI to contact you and remind you of an appointment. An example of this is, leaving a message on your answering machine.
5. Release of Information to Family/Friends – This clinic may release your PHI to a friend or family member that is involved in your care. For example, if a friend, babysitter, grandparent, or other family member brings you or your child to the clinic for care, they will receive medical information about you or that child.
6. Disclosures Required by Law – This clinic will use and disclose your PHI when we are required to do so by federal, state, and/or local law.
Uses and Disclosure of your PHI in Certain Special Circumstances:
1. Public Health Risks – This clinic may disclose your PHI to public health authorities that are authorized by law to collect information for the purpose of reporting child abuse or neglect, maintaining vital records, preventing or controlling disease, injury or disability, notifying a person regarding a potential risk for spreading or contracting a disease or condition, reporting problems with products or devices, notifying individuals that a product or device they may be using has been recalled, or notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.
2. Health Oversight Activities – This clinic may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities may include investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.
3. Lawsuits and Similar Proceedings – This clinic may use and disclose your PHI in response to a court order, if you are involved in a lawsuit or similar proceedings.
4. Law Enforcement – This clinic may release PHI if asked to do so by a law enforcement official regarding a crime victim. If we are unable to obtain the person’s agreement, concerning what we believe has resulted from criminal conduct, regarding criminal conduct at our offices, in response to a warrant, summons, court order, or similar legal process, to identify/locate a suspect, material witness, fugitive or missing person, or in an emergency, to report a crime.
5. Serious Threats to Health and Safety – This clinic may use and disclose your PHI when necessary to reduce or prevent a serious threat to you or your child’s health and safety or the health and safety of another individual.
6. Military – This clinic may disclose your PHI if you are a member of US or foreign military forces and if required by the appropriate authorities.
7. National Security – This clinic may disclose your PHI to federal officials for intelligence and national security activities authorized by law. We also may disclose your PHI to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.
8. Inmates – This clinic may disclose your PHI to correctional institutions or law enforcement officials if you or your child is an inmate or under the custody of law enforcement officials. Disclosure for these purposes would be necessary for the institution to provide health care service to you or your child, for the safety and security of the institution and to protect your health and safety or the health and safety of other individuals.
9. Worker’s Compensation – This clinic may release your PHI for workers’ compensation and similar programs.
Your Rights Regarding Your PHI:
You have the following rights regarding the PHI that we maintain about you or your child. Request involving your rights must be submitted in writing.
1. Confidential Communications – You have the right to request that our clinic communicate with you about health related issues in a particular manner, or at a certain location. The request must specify the method of contract, or the location where you wish to be contracted. We will accommodate reasonable requests. You do not need to give a reason for your request.
2. Requesting Restrictions – You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment of your care. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. Your request must describe in a clear and concise fashion the information you wish restricted, whether you are requesting to limit our clinic’s use, disclosure or both, and to whom you want the limits to apply.
3. Inspection and Copies – You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you or your child, including patient medical records, and billing records. This clinic may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial.
4. Amendment – You may ask us to amend your health information if you believe it is incorrect or incomplete. You may request an amendment for as long as the information is kept by or for this clinic. You must provide us with a reason that supports your request for the amendment. Also, we may deny your request if you ask us to amend information that is in our opinion accurate and complete, not part of the PHI, not created by our clinic, or the individual/entity that created the information is not available to amend the information.
5. Accounting of Disclosure – All of our patients have the right to request on “accounting of disclosures” which is a list of certain non-routine disclosures our clinic has made of your PHI for non-treatment, non-payment, or non-operations purposes. Use of your PHI as part of the routine patient care in our clinic is not required to be documented. All requests for an “accounting of disclosures” must state a time period, which may not be longer than six years from the date of disclosure and may not include dates before April 15, 2003.
6. Right to a Paper Copy of this Notice – You are entitled to receive a paper copy of this notice of privacy practices at any time. A written request is not required.
7. Right to File a Complaint – If you believe your privacy rights have been violated, you may file a complaint with this clinic’s privacy officer, the Office of Civil Rights, or the Secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint.
8. Right to Provide an Authorization for Other Uses and Disclosure – This clinic will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of you or your child’s PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in this authorization. Please note we are required to retain records of your care.
This clinic reserves the right to revise or amend the Notice of Privacy Practices. Any revisions to this notice will be effective for any records that this clinic has created or maintained in the past or will create or maintain in the future.

Certain sleep disorders require an overnight observation in our sleep center. The overnight sleep study is a non-invasive, painless evaluation of your sleep. During the overnight sleep study (polysomnogram), brainwave activity, eye movements, muscle contractions, heart activity, breathing, and blood oxygenation will be measured.

On the night of your study you will be asked to report to the sleep center between 8:00pm and 9:30pm to prepare for your sleep study.

HOW TO PREPARE:
• Avoid napping the day of your sleep study
• Avoid alcohol, caffeine, sedatives, and stimulants 24 hours prior to your study
• Eat your regular evening meal before you arrive at the sleep center
• On the day of the study, be sure that your hair is free of oil, hair spray, and other products
• Bring comfortable sleep attire
• Bring any and all necessary forms and paperwork
• Bring your regularly scheduled medications and plan to take them as you normally would unless your physician instructs otherwise
• If you are under 18 years of age, a parent or guardian is required to stay with you in the sleep center
• Notify us if you have a disability that requires special assistance and we will be happy to accommodate your needs

COMMON QUESTIONS:

“What should I bring to my sleep study?”
- Pack as you would for an overnight stay in a hotel or spa. For the benefit of your comfort and privacy, please bring appropriate and comfortable sleep attire (ie. night gown or pajamas). We have bathroom and shower facilities available for your convenience.
“What if I’m running late for my sleep study?”
- Please contact our lab directly at (907) 743-0050 and let us know what time you expect to arrive. 
“What happens when I arrive at the sleep center for my study?”
- Sleep studies usually begin in the late evening and end at about 5:30am-6:30am the following day. Once you arrive at the center, one of our wonderful sleep technologists will welcome you and show you to your private bedroom. The technologist will verify that all necessary forms are completed and answer any questions you may have.
“Will I have my own room?”
- Yes, our sleep study bedrooms are private.
“Will I be able to sleep with the monitoring equipment attached to me?”
- Most people do not find it uncomfortable at all, nor an obstacle to falling asleep. We make every effort to ensure that you are as comfortable as possible. Should any issues with your comfort arise, your sleep technologist will make adjustments. Your bedroom has an open intercom that will enable you to communicate with your technologist at any time.
“What if I need to go to the bathroom during the study?”
- If you need to use the bathroom at any point during the night, you can call you sleep technologist on the intercom for assistance. They will temporarily disconnect your monitoring equipment to allow you to use the facilities.
“When can I leave the sleep center?”
- Studies are completed between 5:30am-6:30am. You should plan on adding an additional 30 minutes to your morning routine to account for time to allow your sleep technologist to remove the monitoring equipment. You may take a shower to wash away any remaining gels and pastes used with the monitoring equipment. If you need to be ready to leave the center at a certain time, please let us know when you arrive at the center so we can accommodate your request.
“Does the sleep center provide breakfast?”
- The sleep center is set up with a small kitchenette and we will provide a light, complimentary breakfast. Selections may include breakfast bars, oatmeal, coffee, teas, and juices. A refrigerator and microwave are available for your convenience. You are more than welcome to use the kitchenette area or ask your sleep technologist for assistance.
“What happens after my sleep study?”
- A large amount of information is collected during your study. This information is reviewed by your sleep technologist, and finally our Medical Director. Once our Medical Director has reviewed the information he creates a formal report that will be sent to your doctor.
“When will my doctor receive my results?”
- It usually takes 2-5 business days for your doctor to receive your formal report. 

Once again we would like to say “THANK YOU!” for choosing Anchorage Sleep Center, LLC for your sleep needs!