New Patient Paperwork

Welcome to Complete Sleep Relief,
Your provider has scheduled you for an in-home sleep study with Complete Sleep Relief. This is a simple procedure that can provide valuable insights into your sleep.
Our company is in Brighton, Colorado. Complete Sleep Relief provides in home sleep testing. The device we use is the Apnea Link Air Plus. The device is wireless and easy to use. Our company makes scheduling the in-home sleep study easy and convenient.We mail the unit directly to you utilizing the United States Postal Service.
Your results of the completed study will be interpreted by a board-certified sleep physician. The results will be sent to your ordering provider within 48 hours of receiving the device back from you. Please contact your provider for the results of your study, as Complete Sleep Relief does not go over the results of the in-home sleep study with you.
Please visit our website www.completesleeprelief.com, to view our video on “How to use the device,” prior to testing. Written instructions on how to use the device are also included in the sleep testing kit.
The new patient paperwork needs to be completed and any payment you may owe needs to be taken care of before we mail out your in-home sleep study device. Please contact us if you have any questions regarding the paperwork.
Once you have had your sleep study please complete our patient satisfaction survey. Do not hesitate to give us service improvement ideas, which will help us in our goal to continually improve how we service patient’s and conduct business.
Sincerely,
The Complete Sleep Relief

Registration Information

Patient First and Last Name*

First Last

MI

Date of Birth*

Gender*

Male
Female

Home Phone

Cell Phone*

Email

Address*

Street Address City State / Province / Region ZIP / Postal Code

Employer Name

Work Phone

Emergency Contact*

Phone*

Relationship to Emergency Contact*

Primary Care Physician*

Medications: List Current medications and Dosages, including both prescription and over-the-counter medications:*

Allergies:*

Patient Consent for Treatment/Assignment of Benefits Agreement/Costs

Assignment of Insurance Benefits: I authorize direct remittance of payment of all insurance benefits to CSR forall covered services, and I authorize CSR to act as my Designated Representative concerning all aspects of insurance claim filing, including, but limited to, appeals for products or services rendered by CSR. I authorize my insurance company to mail ALL PAYMENTS directly to CSR. In an event the insurance company mails me, the patient, a check I will forward the payment to CSR within 7 days of receipt of check. In the event, I, the patient, do not forward the check I, the patient, will be held responsible for thepayment amount provided by my insurance carrier. I also understand the Explanation of Benefits (EOB) from my insurance carrier is NOT a bill from CSR. In the event your insurance company does not cover the total charge or a portion of the charge for your sleep study, it will be my responsibility to pay the full or remaining balance of the statement from CSR. (This is not your EOB, but a statement from CSR )

I understand that a fee may be charged by CSR on all accounts 60 days or more past due. (This excludes any patient on a payment arrangement). CSR may charge a fee and interest on any outstanding balance more than 60days past due. A rate of 18% will be added to my account that is over 60 days outstanding. I understand these fees added to my account and hereby agree to pay all unpaid charges. I also understand that in the event my account is placed with a collection agency, and/ or a lawsuit is brought against me to collect any outstanding balance due CSR, I will be responsible for all costs of collections, including, but not limited to, court costs and reasonable attorney fees.
I understand in the event the device is lost, stolen or damaged while in my possession, I am responsible for the replacement of the device. The charge for replacingthe home sleep testing device is $2,500.00.
I understand I must mail the unit back on the 3 RD day from the date I received the device. OR the date that was agreed upon when scheduled. I will have e-mail documentation of this specific date. I understand I will have a $45.00/day fee if the device is not in the mail on the day provided to me. If I choose to not wear the In-Home Sleep testing device after I have received the device, I will be charged with a $75.00 no wear fee. I understand if I smoke, I will not smoke around the equipment. In the event the device is returned smelling like smoke and the device cannot be used again. You will be charged a fee of $395.00.
While the monitoring device is in my possession, I agree to exercise care inits use and handling, and I will return it within the promised timeframe and in working condition. (This does not pertain to the malfunction of a unit; we understand the unit can malfunction)
I have received and reviewed the attached Notice of Privacy Practices, the Patient Rights and Responsibilities, and the Provider Performance Standards; I understand my rights as stated in these documents

My signature represents my acceptance and acknowledgement of each of the above bullet point statements.

Patient Signature*

Date*

PATIENT SERVICE AGREEMENT AND PLAN OF SERVICE- SLEEP TESTING

Patient Name*

First Last

Date*

Authorization/Consent for Care/Service: I, with my signature, authorize Complete Sleep Relief, and any of its employees working under the direction of the Medical Director, to provide medical care for me. Or to the patient for which I am the legal guardian. This medical care may include services related to my healthcare and may include but not limited to preventative, diagnostic, therapeutic, maintenance, assessment and equipment or other items required in accordance with the prescription. The consent includes contact and discussion with other health care professionals for the care and treatment.
Assignment of Benefits/Authorization for Payment: : I hereby assign all benefits and payments to be made directly Complete Sleep Relief for all services furnished to me in conjunction with my care. I authorize Complete Sleep Relief to seek such benefits and payments on my behalf. It is understood that, as a courtesy. Complete Sleep Relief will bill Medicare/Medicaid or other federally funded sources and other payers and insurer(s) providing coverage, with a copy to Complete Sleep Relief I understand that I am responsible for providing all necessary information and for making sure all certification and enrollment requirements are fulfilled. Any changes in the policy must be reported to Complete Sleep Relief within 30 days of the event. I have been informed by Complete Sleep Relief of the medical necessity for the services prescribed by my physician. I understand that in the event services are deemed not reasonable and necessary, payment may be denied and that I will be fully responsible for payment.
Release of Information: : I hereby request and authorize Complete Sleep Relief, the prescribing physician, hospital, and any other holder of information relevant to service, to release information upon request, to Complete Sleep Relief, any payer source, physician, or any other medical personnel or agency involved with service. I also authorize Complete Sleep Relief to review medical history and payer information for the purpose of providing services.
Financial Responsibility: : I understand and agree that l am responsible for the payment of all sums that may become due for the services provided. These sums include, but are not limited to, all deductibles, co-payments, out-of-pocket requirements, and non-covered services. If for any reason and to any extent, Complete Sleep Relief does not receive payment from my payer source, I hereby agree to pay Complete Sleep Relief for the balance in full, within 30 days of receipt of invoice. All charges not paid within 90 days of billing date shall be assessed late charges. I am liable for all charges, including collection costs and all attorneys cost. I am responsible for all charges regardless of my payer unless my agreement with my health plan holds me harmless.
I have read and understand the patient service agreement and plan of service

Patient Signature:*

HIPAA PATIENT ACKNOWLEDGEMENT

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
You may refuse to sign this acknowledgement but, in refusing we will not be allowed to process your insurance claims.

Date*

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for Complete Sleep Relief. A copy of this signed, dated Acknowledgement shall be as effective as the original.

Please print your name*

Please sign your name*

PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTHCARE INFORMATION:
(This includes stepparents, grandparents and any care takers who can have access to this patient’s records):

Name

First Last

Relationship

Name

First Last

Relationship

I AUTHORIZE CONTACT FROM THIS OFFICE TO CONFIRM MY HEALTHCARE APPOINTMENTS, TREATMENT & BILLING INFORMATION VIA:

Please place an X next to the box you wish to choose

Cell Phone Confirmation
Home Phone Confirmation
Work Phone Confirmation
Email
Text Message
Any of the above

Patient Signature:*

Date*

Patient Handouts: I acknowledge that I have received a copy of the Patient Handouts which contains Patient Rights and Responsibilities, HIPAA Privacy Standards and Complaint/Grievance Reporting. I acknowledge that the information in the Patient Handouts has been explained to me and that I understand the information. (Attached at the end of paperwork)
Grievance Reporting: I acknowledge that I have been informed of the procedure to report a grievance should I become dissatisfied with any portion of my experience. I understand that I may lodge a complaint without concern for reprisal, discrimination, or unreasonable interruption of service. To place a grievance, please call (720) 408-9406 and speak to the Compliance Officer. If your complaint is not resolved to your satisfaction within 5 working days, you may initiate a formal grievance, in writing and forward it to the Governing Body. You can expect a written response within 14 working days or receipt.

You may also make inquiries or complaints about this company by calling 1-800-MEDICARE and/or the Accreditation Commission for Health Care (ACHC) at 919-785-1214.

PLAN OF SERVICE

Identified Needs/Problems:
The patient is or may be unfamiliar with Sleep Disorders and Sleep Studies to diagnose Sleep Disorders, the patient may require follow-up services.
Expected Outcomes:
The patient will be provided sleep testing to comply with the physician’s prescription/orders.
The patient will communicate to the staff any questions and concerns.
The patient will know how to obtain follow-up services as needed.
Services/Actions Provided:
Perform patient assessment and perform ordered testing.
Provide Sleep Disorder Education.
Provide written handout for Patient Bill of Rights and Responsibilities, HIPAA Privacy Standards and Grievance Reporting
Provide written instructions for obtaining follow-up services

Patient Signature*

Date*

INSTRUCTIONS ON HOW TO USE THE DEVICE: Resmed ApniaLink Air

A “How To” video can be found at: https://www.youtube.com/watch?v=awa4z2fFn7A
Please place batteries (provided) in the device before testing for night 1. REPLACE the batteries before testing for night 2.
Please make sure you tape the nasal cannula to your cheek and oximeter to your wrist or finger. This will keep them in place.
Females- The device can be placed across your breast or below them, whichever is more comfortable.
Indicator lights will go green and red throughout the night. Please do NOT worry about these lights
You may sleep in any position you would like once the device is in place. If you wake up for any reason in the middle of the night leave the device on and in place. If you need to remove the finger prob—do so, then place it back.

PLEASE CALL OUR OFFICE IF YOU HAVE ANY QUESTIONS REGARDING TESTING OF THIS DEVICE. OUR VOICEMAIL WILL PROVIDE A NUMBER THAT YOU CAN CALL FOR AFTER HOUR ASSISTANCE.
OFFICE PHONE NUMBER: 720-408-9406
THANK YOU FOR TESTING WITH COMPLETE SLEEP RELIEF

Signature that you have received these instructions

Patient Signature:*

Date*

Patient’s Name*

First Last

DOB*

Height*

Weight*

Neck Size*

Are you a Mouth Breather?*

Yes
No

Have you been diagnosed or tested for any of the following conditions? Yes=Y or No=N

High Blood Pressure?*

Heart Disease?*

Diabetes?*

Lung Disease?*

Insomnia?*

Narcolepsy?*

Sleeping Medications?*

Stroke?*

Depression?*

Sleep Apnea?*

Nasal oxygen Use?*

Restless Leg Syndrome?*

Morning Headaches?*

Pain Medications?*

Epworth Sleepiness Scale: How likely are you to doze off or fall asleep in the following situations in contrast to just felling tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to mare the most appropriate box for each situation.
0= would never doze, 1= slight chance of dozing, 2= moderate chance of dozing, 3= high chance of dozing

Sitting and reading*

Watching T.V*

Sitting, inactive, in a public place (theater, meeting, etc.)*

As a passenger in a car for an hour without a break*

Lying down to rest in the afternoon*

Sitting and talking to someone*

Sitting quietly after lunch without alcohol*

In a car, while stopped for a few minutes in traffic*

NEVER=0, RARELY=1, SOMETIMES=2, FREQUENTLY=3

On average in the past month, how often have you snored or been told you snore?*

Do you wake up choking or gasping?*

Have you been told you stop breathing in your sleep?*

Do you have problems keeping your legs still at night or need to move them to feel comfortable?*

HIPAA PRIVACY NOTICE

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
OUR COMMITMENT TO YOUR PRIVACY
It is our duty to maintain the privacy and confidentiality of your protected health information (PHI). We will create records regarding your and the treatment and service we provide to you. We are required by law to maintain the privacy of your PHI, which includes any individually identifiable information that we obtain from you or others that relates to your past, present or future physical or mental health, the health care you have received, or payment for your health care. We will share protected health information with one another, as necessary, to carry out treatment, payment or health care operations relating to the services to be rendered at the company.

As required by law, this notice provides you with information about your rights and our legal duties and privacy practices with respect to the privacy of PHI. This notice also discusses the uses and disclosures we will make of your PHI. We must comply with the provisions of this notice as currently in effect, although we reserve the right to change the terms of this notice from time to time and to make the revised notice effective for all PHI we maintain. You can always request a written copy of our most current privacy notice from our Privacy Officer.

PERMITTED USES AND DISCLOSURES

We can use or disclose your PHI for purposes of treatment, payment and health care operations. For each of these categories of uses and disclosures, we have provided a description and an example below. However, not every particular use or disclosure in every category will be listed.

Treatment means providing services as ordered by your physician. Treatment also includes coordination and consultations with other health care providers relating to your care and referrals for health care from one health care provider to another. We may also disclose PHI to outside entities performing other services related to your treatment such as hospital, diagnostic laboratories, home health or hospice agencies, etc.

Payment means the activities we undertake to obtain reimbursement for the health care provided to you, including billing, collections, claims management, prior approval, determinations of eligibility and coverage and other utilization review activities. Federal or state law may require us to obtain a written release from you prior to disclosing certain specially protected PHI for payment purposes, and we will ask you to sign a release when necessary under applicable law.

Health care operations means the support functions of the company, related to treatment and payment, such as quality assurance activities, case management, receiving and responding to patient comments and complaints, physician reviews, compliance programs, audits, business planning, development, management and administrative activities. We may use your PHI to evaluate the performance of our staff when caring for you. We may also combine PHI about many patients to decide what additional services we should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose PHI for review and learning purposes. In addition, we may remove information that identifies you so that others can use the de-identified information to study health care and health care delivery without learning who you are.

OTHER USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
We may also use your PHI in the following ways:

To provide appointment reminders for treatment or medical care.
To tell you about or recommend possible treatment alternatives or other health-related benefits and services that may be of interest to you
To disclose to yourfamily or friends or any other individual identified by you to the extent directly related to such person'sinvolvement in your care or the payment for your care. We may use or disclose your PHI to notify, or assist in the notification of, a family member, a personal representative, or another person responsible for your care, of your location, general condition or death. If you are available, we will give you an opportunity to object to these disclosures, and we will not make these disclosures if you object. If you are not available, we will determine whether a disclosure to your family or friends is in your best interest, taking into account the circumstances and based upon our professionaljudgmen

When permitted by law, we may coordinate our uses and disclosures of PHI with public or private entities authorized by law or by charter to assist in disaster relief efforts.
We will allow your family and friends to act on your behalf to pick up filled prescriptions, medical supplies, X-rays, and similar forms of PHI, when we determine, in our professional judgment that it is in your best interest to make such disclosures.
We may contact you as part of our fundraising and marketing efforts as permitted by applicable law. You have the right to opt out of receiving such fundraising communications.
We may use or disclose your PHI for research purposes, subject to the requirements of applicable law. For example, a research project may involve comparisons of the health and recovery of all patients who received a particular medication. All research projects are subject to a special approval process which balances research needs with a patient's need for privacy. When required, we will obtain a written authorization from you prior to using your health information for research.
We will use or disclose PHI about you when required to do so by applicable law.
In accordance with applicable law, we may disclose your PHI to your employer if we are retained to conduct an evaluation relating to medical surveillance of your workplace or to evaluate whether you have a work-related illness or injury. You will be notified of these disclosures by your employer or the company as required by applicable law.
Note: incidental uses and disclosures of PHI sometimes occur and are not considered to be a violation of your rights. Incidental uses and disclosures are by-products of otherwise permitted uses or disclosures which are limited in nature and cannot be reasonably prevented.

SPECIAL SITUATIONS
Subject to the requirements of applicable law, we will make the following uses and disclosures of your PHI:
Organ and Tissue Donation If you are an organ donor, we may release PHI to organizations that handle organ procurement or transplantation as necessary to facilitate organ or tissue donation and transplantation.
Military and Veterans If you are a member of the Armed Forces, we may release PHI about you as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate foreign military authority.
Worker's Compensation We may release PHI about you for programs that provide benefits for work-related injuries or illnesses.
Public Health Activities We may disclose PHI about you for public health activities, including disclosures:

to prevent or control disease, injury ordisability;
to report births and deaths;
to report child abuse orneglect;
to persons subject to the jurisdiction of the Food and Drug Administration (FDA) for activities related to the quality, safety, or effectiveness of FDA-regulated products or services and to report reactions to medications or problems with products;
to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
to notify the appropriate government authority if we believe that an adult patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if the patient agrees or when required or authorized by law.

Health Oversight Activities We may disclose PHI to federal or state agencies that oversee our activities (e.g., providing health care, seeking payment, and civil rights).
Lawsuits and Disputes If you are involved in a lawsuit or a dispute, we may disclose PHI subject to certain limitations.
Law Enforcement We may release PHI if asked to do so by a law enforcement official:

In response to a court order, warrant, summons orsimilar process;
To identify or locate a suspect, fugitive, material witness, or missing person;
About the victim of a crime under certain limited circumstances;
About a death we believe may be the result of criminal conduct;
About criminal conduct on our premises;or
In emergency circumstances, to report a crime, the location of the crime or the victims, or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors We may release PHI to a coroner or medical examiner. We may also release PHI about patients to funeral directors as necessary to carry out their duties
National Security and Intelligence Activities We may release PHI about you to authorized federal officials for intelligence, counterintelligence, other national security activities authorized by law or to authorized federal officials so they may provide protection to the President or foreign heads of state.
Inmates If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release PHI about you to the correctional institution or law enforcement official. This release would be necessary (1) to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
Serious Threats As permitted by applicable law and standards of ethical conduct, we may use and disclose PHI if we, in good faith, believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public or is necessary for law enforcement authorities to identify or apprehend an individual.
Note: HIV-related information, genetic information, alcohol and/or substance abuse records, mental health records and other specially protected health information may enjoy certain special confidentiality protections under applicable state and federal law. Any disclosures of these types of records will be subject to these special protections.
OTHER USES OF YOUR HEALTH INFORMATION

Certain uses and disclosures of PHI will be made only with your written authorization, including uses and/or disclosures: (a) of psychotherapy notes (where appropriate); (b) for marketing purposes; and (c) that constitute a sale of PHI under the Privacy Rule. Other uses and disclosures of PHI not covered by this notice or the laws that apply to us will be made only with your written authorization. You have the right to revoke that authorization at any time, provided that the revocation is in writing, except to the extent that we already have taken action in reliance on your authorization.
YOUR RIGHTS

You have the right to request restrictions on our uses and disclosures of PHI for treatment, payment and health care operations. However, we are not required to agree to your request unless the disclosure is to a health plan in order to receive payment, the PHI pertains solely to your health care items or services for which you have paid the bill in full, and the disclosure is not otherwise required by law. To request a restriction, you may make your request in writing to the Privacy Officer.
You have the right to reasonably request to receive confidential communications of your PHI by alternative means or at alternative locations. To make such a request, you may submit your request in writing to the Privacy Officer.
You have the right to inspect and copy the PHI contained in our company records, except:

for psychotherapy notes, (i.e., notes that have been recorded by a mental health professional documenting counseling sessions and have been separated from the rest of your medical record);
for information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding;
for PHI involving laboratory tests when your access is restricted by law;
if you are a prison inmate, and access would jeopardize your health,safety,security, custody, or rehabilitation orthat of otherinmates, any officer, employee, or other person at the correctional institution or person responsible for transporting you;
if we obtained or created PHI as part of a research study, your access to the PHI may be restricted for as long as the research is in progress, provided that you agreed to the temporary denial of access when consenting to participate in the research;
for PHI contained in records kept by a federal agency or contractor when your access is restricted by law; and
for PHI obtained from someone other than us under a promise of confidentiality when the access requested would be reasonably likely to reveal the source of theinformation.

In order to inspect or obtain a copy your PHI, you may submit your request in writing to the Medical Records Custodian. If you request a copy, we may charge you a fee for the costs of copying and mailing your records, as well as other costs associated with your request.
We may also deny a request for access to PHI under certain circumstances if there is a potential for harm to yourself or others. If we deny a request for access for this purpose, you have the right to have our denial reviewed in accordance with the requirements of applicable law.
4. You have the right to request an amendment to your PHI but we may deny your request for amendment, if we determine that the PHI or record that is the subject of therequest:

was not created by us, unless you provide a reasonable basis to believe that the originator of PHI is no longer available to act on the requested amendment;
is not part of your medical or billing records or other records used to make decisions about you;
is not available for inspection as set forth above; or
is accurate andcomplete.

In any event, any agreed upon amendment will be included as an addition to, and not a replacement of, already existing records. In order to request an amendment to your PHI, you must submit your request in writing to Medical Record Custodian at our company, along with a description of the reason for your request.
5. You have the right to receive an accounting of disclosures of PHI made by us to individuals or entities other than to you for the six years prior to your request, except fordisclosures:

to carry out treatment, payment and health care operations as provided above;
) incidental to a use or disclosure otherwise permitted or required by applicable law;
) pursuant to your written authorization;

to persons involved in your care or for other notification purposes as provided by law;
for national security or intelligence purposes as provided bylaw;
to correctional institutions or law enforcement officials as provided by law;
as part of a limited data set as provided bylaw.

To request an accounting of disclosures of your PHI, you must submit your request in writing to the Privacy Officer at our company. Your request must state a specific time period for the accounting (e.g., the past three months). The first accounting you request within a twelve (12) month period will be free. For additional accountings, we may charge you for the costs of providing the list. We will notify you of the costs involved, and you may choose to withdraw or modify your request at that time before any costs are incurred.
6. You have the right to receive a notification, in the event that there is a breach of your unsecured PHI, which requires notification under the Privacy Rule.
COMPLAINTS
If you believe that your privacy rights have been violated, you should immediately contact the company's Privacy Officer. We will not take action against you for filing a complaint. You also may file a complaint with the Secretary of the U. S. Department of Health and Human Services, 200 Independence Ave. S.W., Washington DC, 20201.

Grievance / Complaint Reporting:

You may lodge a complaint without concern for reprisal, discrimination, or unreasonable interruption of service. To place a grievance, please call (720) 408-9406 and speak to customer services. If your complaint is not resolved to your satisfaction within 5 working days, you may initiate a formal grievance, in writing and forward it to the Governing Body. You can expect a written response within 14 working days or receipt.

You may also make inquiries or complaints about this company by calling Medicare at 1-800-MEDICARE and/or the Accreditation Commission for Health Care (ACHC) at 919-785-1214.

Welcome to Complete Sleep Relief A Simple Sleep Testing Solution

New patient

Registration Information

Patient Consent for Treatment/Assignment of Benefits Agreement/Costs

PATIENT SERVICE AGREEMENT AND PLAN OF SERVICE- SLEEP TESTING

HIPAA PATIENT ACKNOWLEDGEMENT

PLAN OF SERVICE

INSTRUCTIONS ON HOW TO USE THE DEVICE: Resmed ApniaLink Air

HIPAA PRIVACY NOTICE

Registration Information

Patient Consent for Treatment/Assignment of Benefits Agreement/Costs

PATIENT SERVICE AGREEMENT AND PLAN OF SERVICE- SLEEP TESTING

HIPAA PATIENT ACKNOWLEDGEMENT

PLAN OF SERVICE

INSTRUCTIONS ON HOW TO USE THE DEVICE: Resmed ApniaLink Air

HIPAA PRIVACY NOTICE