Non-Coverage and Patient Financial Responsibility for Single-Night HSAT

Non-Coverage and Patient Financial Responsibility for Single-Night HSAT
Patient Name

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Service:

Home Sleep Apnea Test (HSAT) – unattended sleep study performed at home.

Reason Insurance May Not Pay:

- Your plan may cover only certain types of sleep studies (in-lab vs. home testing).

- Coverage may depend on specific medical necessity criteria.

- If this is a repeat test, or performed for conditions not recognized by your plan, it may not be covered.

- Your insurance benefits may be exhausted, or you may not have prior authorization.

Estimated Cost: $250
YES. I want to proceed with the HSAT. I understand my insurance may not cover it and agree to pay the full cost if denied.NO. I do not want the HSAT.
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