Consent to Treatment: I consent to and authorize the attending physician, the associated sleep facility personnel, and any other consulting physician called in by the above, to render medical treatment and healthcare services to the patient named on this form.
Consent to Video Recording: I authorize Mountain Sleep to videotape, record, and/or photograph me as part of my care. This allows direct observation by the technologist. I understand that this photo is a necessary and integral part of my diagnostic procedure. Any such photograph, videotape or film will be kept as part of my medical records generally, and will be released only pursuant to my consent or in accordance with other appropriate procedures for release of medical information. I understand any caregiver or guess staying with me during my test will be videotape, record, and/or photograph as part of the safety of staff and patient care.
Consent for CPAP/BIPAP Trial: I consent to a trial of continuous positive airway pressure (CPAP) / bi-level positive airway pressure (BIPAP), to be delivered by nose in the sleep facility. I understand that although the treatment is considered quite safe, it may lead to nasal congestion or stuffiness. Escape of air upward from the nasal mask could cause drying and irritation of the eyes, and I understand that the technologist will minimize this possibility by carefully fitting the nasal mask. I recognize that occasional instances of distention of the stomach by air have been reported. I acknowledge that although most sleep apnea patients have shown benefit from nasal CPAP/BIPAP, no guarantees are given as to the success in my particular case.
Policy on Drugs and Prescriptions: It is understood that Mountain Sleep wants you to take your regularly scheduled prescription medications on the night of the sleep study. Please make sure all of your medications are known to the office staff and the sleep laboratory staff the night of the study. Illegal drugs are not permitted.
Financial Policy for Patients (Page 1)
We provide the best possible care and service to you, and we want you to completely understand our financial policies.
1.) Payment is due at the time of service unless arrangements have been made in advance. We accept Cash, Check, Money Order, VISA, Master Card,American Express & Discovery.
2.) Keep in mind that your insurance policy is a contract between you and your insurance company. As a courtesy to you, we will verify your benefits. However, not all insurance plans cover certain services. Please note that all insurances give this insurance disclaimer: “A quote of benefits and/or coverage does not guarantee payment by your insurance company. Payment of benefits are subject to all terms, conditions, limitations, and exclusions of your policy at the time of service.” Therefore, until we file the claim, we cannot guarantee what your policy will pay. If your insurance company denies the claim for non-covered service, the deductible has not been met, out of network with no coverage for out of network benefits, then we will look to you for payment. Any unpaid balances by insurance will be your responsibility. It is your responsibility to be familiar with your insurance company and your specific plan requirements.
As of March 2019, Mountain Sleep and Respiratory Medicine will required a Credit/Debit card to be placed on file for anyone requiring an in lab sleep study that is one of the following self-pay, your insurance has an HRA/HSA/flex spending account that we cannot verify the balance on the account and therefore the claim has to be file first before payment from HRA/HSA or Flex Spending Account, Insurance that has termed or insurance that cannot be verified prior to your in lab sleep study ( in which you would be responsible for the self-pay price of office visits and sleep study). Payment Plan will be required for any services not paid prior to when service will be rendered. Refusal to provide this will result in a denial of the provision of services.
Payment Plans are made up to 3 months if balance is or becomes over $600.00. Ask at the front desk or call our billing department for details.
Keep in mind payment is always due at the time of service for office visits and home sleep studies. If payment is made in full for every service regardless then a credit card will not be required, however if insurance comes back with a different amount due, this will be billed to you and if not received we will expect payment at your next visit or we will not be able to render any further services until payment is made.
Financial Policy for Patients (Page 1)
We provide the best possible care and service to you, and we want you to completely understand our financial policies.
1.) Payment is due at the time of service unless arrangements have been made in advance. We accept Cash, Check, Money Order, VISA, Master Card,American Express & Discovery.
2.) Keep in mind that your insurance policy is a contract between you and your insurance company. As a courtesy to you, we will verify your benefits. However, not all insurance plans cover certain services. Please note that all insurances give this insurance disclaimer: “A quote of benefits and/or coverage does not guarantee payment by your insurance company. Payment of benefits are subject to all terms, conditions, limitations, and exclusions of your policy at the time of service.” Therefore, until we file the claim, we cannot guarantee what your policy will pay. If your insurance company denies the claim for non-covered service, the deductible has not been met, out of network with no coverage for out of network benefits, then we will look to you for payment. Any unpaid balances by insurance will be your responsibility. It is your responsibility to be familiar with your insurance company and your specific plan requirements.
As of March 2019, Mountain Sleep and Respiratory Medicine will required a Credit/Debit card to be placed on file for anyone requiring an in lab sleep study that is one of the following self-pay, your insurance has an HRA/HSA/flex spending account that we cannot verify the balance on the account and therefore the claim has to be file first before payment from HRA/HSA or Flex Spending Account, Insurance that has termed or insurance that cannot be verified prior to your in lab sleep study ( in which you would be responsible for the self-pay price of office visits and sleep study). Payment Plan will be required for any services not paid prior to when service will be rendered. Refusal to provide this will result in a denial of the provision of services.
Payment Plans are made up to 3 months if balance is or becomes over $600.00. Ask at the front desk or call our billing department for details.
Keep in mind payment is always due at the time of service for office visits and home sleep studies. If payment is made in full for every service regardless then a credit card will not be required, however if insurance comes back with a different amount due, this will be billed to you and if not received we will expect payment at your next visit or we will not be able to render any further services until payment is made.
In-lab Sleep studies:
We understand that this amount is not known until your consultation appointment and can sometimes be expensive with different insurance or paying self-pay, in these cases we will allow payment up to 4:00 pm the day before your sleep study appointment. If payment is not received for the inlab sleep study, your sleep study could be canceled due to failure of payment. If we cannot reach you, we will let the front desk know we have canceled your study and for you to contact us at the opening of business the next day.
Your credit card/debit card details and other billing information are stored in compliance with the highest safety and security standards. We follow these regulations to help protect the personal data of our patients.
3.). We have made prior arrangements with many insurance companies and other health plans to accept an Assignment of Benefits. As a courtesy, we will file your insurance claim per the Assignment of Benefits, which means your insurance company will make payment directly to Mountain Sleep. If your insurance does not pay the practice within a reasonable period of time (within 90 days), we will look to you for payment.
4.) If you have insurance coverage with a plan with whom we do not have a prior agreement, charges for your care are due at the time of the service.
In-lab Sleep studies:
We understand that this amount is not known until your consultation appointment and can sometimes be expensive with different insurance or paying self-pay, in these cases we will allow payment up to 4:00 pm the day before your sleep study appointment. If payment is not received for the inlab sleep study, your sleep study could be canceled due to failure of payment. If we cannot reach you, we will let the front desk know we have canceled your study and for you to contact us at the opening of business the next day.
Your credit card/debit card details and other billing information are stored in compliance with the highest safety and security standards. We follow these regulations to help protect the personal data of our patients.
3.). We have made prior arrangements with many insurance companies and other health plans to accept an Assignment of Benefits. As a courtesy, we will file your insurance claim per the Assignment of Benefits, which means your insurance company will make payment directly to Mountain Sleep. If your insurance does not pay the practice within a reasonable period of time (within 90 days), we will look to you for payment.
4.) If you have insurance coverage with a plan with whom we do not have a prior agreement, charges for your care are due at the time of the service.
You authorize charges to your credit card representing copays, deductibles and/ or non-covered charges. Your payment will always be on time, eliminating the possible late charges and mitigating collections activity on your account.
I understand that this authorization will remain in effect until I cancel in writing at least 20 days prior to the next billing date or make other payment arrangements. In the case of a Declined Transaction, I understand that Mountain Sleep and Respiratory Medicine may attempt to process the charge again within 30 days and agree to an additional $25 charge for each attempt due to Decline Transactions from my credit card due to insufficient funds or other issues not related to Mountain Sleep and Respiratory Medicine. I certify that I am an authorized user on this credit card and will not dispute these scheduled transactions with my bank or credit card company; so long as the transactions correspond to the terms indicated in this authorization form.
1. We ask that family and friends do NOT accompany you to our sleep center. This is due to the current COVID19 policy we have in place for our lab. The only exception will be patients under the age of 18 or patients with special needs. In this case we will allow one person to stay in the same room, if available and confirmed but the ordering provider.
2. This person must not snore or have any other sleep habits that might interfere with your study. If this happens, it could cause you to have to return for a repeat study. In this case insurance will not pay for a repeat sleep study.
3. If anyone comes with you who has not been authorized to be there, they will be sent home. We appreciate your cooperation in this matter. Please sign below stating your acknowledgement of this policy.
4. We will also be screening for COVID19, and we have extensive cleaning/contact protocol to keep you and our staff safe.
5. Mountain Sleep keeps a nightly list of all patients so when you check in they know who you are and give you a key. This list is held at the front desk of the hotel in case of an emergency or family/friend inquiry. Your signature below will be your consent to be added to this list. Also, please list any additional names of any person(s) that may be told your whereabouts during your stay, should an inquiry be made. No information will be given to any person not listed on Hippa Form.
I give Mountain Sleep and the Crowne Plaza Resort permission to list my name on their nightly patient roster.