Informed Consent Form for At-Home Sleep Study
Purpose: The purpose of this study is to assess your sleep for airflow, respiratory effort, and blood oxygenation using SleepView home sleep study equipment through Clevemed. This is to assess for obstructive sleep apnea and may not diagnose other sleep disorders.
Procedures: You will be provided with a sleep monitoring device that you will use at home. The device will record information about your sleep patterns, such as duration, movements, and breathing. Detailed instructions on how to use the device will be provided. You then will bring back the equipment before noon the next day to be uploaded to the sleep specialist team for interpretation.
Risks and Discomforts: There may be minimal discomfort associated with wearing the sleep monitoring device. In rare cases, participants may experience mild skin irritation or discomfort. You should be careful not to have the nasal cannula too tight around your head or neck. Keep out of reach from small children. If you experience any adverse effects, you should contact the office immediately.
Benefits: Timely and easy assessment of your sleep quality at home with a full report and interpretation provided by iSleep board-certified sleep specialist physicians within days of testing as well as a referral for any treatment/therapies recommended.
Insurance: The nature of this test being packaged with interpretation, report of findings and referrals if necessary means that insurance cannot be billed. This allows the clinic to keep the price of this service as low as possible and affordable. You may pay with an HSA/FSA card.
Cost: The cost of the use of this equipment, processing of test, interpretation of test with a full report and referral to a sleep medicine team if necessary is $180. The equipment should be only used for one night. Any additional day that you have the equipment will incur a $100 fee. Credit card will be kept on file. If you do not return the equipment within one week of testing, you will be responsible for the entire cost of replacing the equipment, $2600. There will be no refunds after the equipment has been picked up, regardless of results.
Consent: I have read and understood the information provided in this consent form. I have had the opportunity to ask questions and have received satisfactory answers. I agree to the financial responsibilities and understand the risks and benefits.