The following SSDC Service(s) Consent, Member Authorization Form for a Designated Representative to Appeal a Determination, SSDC Additional Disclosures, SSDC Consent for Use and Disclosure of PT Health Information – HIPAA and Privacy Notice, and SSDC Authorization to Release PT Medical Records are required disclosures, notices, and consent forms executed by and for the identified Patient and/or the Patient's legal caregiver, guardian, or duly authorized individual (individually and jointly, "PT") by and between PT and SleepSomatics [together, doing business as SleepSomatics or SleepSomatics Diagnostic Center, SleepSomatics LP (TIN 20-4601197 NPI 1538251202) and EL’Lucre Management Corp (TIN 52-2416115 NPI 1013191386)] whose physical location is 2211 W Parmer Ln, Ste A, Austin, TX, 78727 and whose telephone number is (512) 323-9253 and whose fax is (512) 323-9254 (individually and collectively, "SSDC") for the purposes stated herein (collectively, the "Agreement").
By signing below, I confirm that I am the below-identified patient. I am initiating an electronic signature to confirm my acknowledgement, understanding, and acceptance of this Agreement. My electronic signature is made in accordance with the Electronic Signatures in Global and National Commerce Act (ESIGN) and the Uniform Electronic Transactions Act (UETA). I understand that misrepresentation of my identity is a federal crime. I further understand that by signing below, I am accepting and agreeing to the SleepSomatics Terms of Use, which is available to me at sleepsomatics.com. I may request a free printed copy by calling SleepSomatics during daytime administrative hours. I acknowledge and agree that my execution of this Agreement and my signature for said execution shall be valid for twelve (12) months from the date of my execution of this Agreement for all Service(s) provided by SSDC to me during said twelve (12) months.
I have thoroughly reviewed and read this Agreement (or waived review and reading) and voluntarily acknowledge, understand, accept, agree to, and execute this entire Agreement.
SSDC Service(s) Consent
PT acknowledges that the purpose of this Agreement is to establish, provide, fulfill, and bill his or her ordering or treating healthcare provider-ordered sleep diagnostic appointment which may include procedures, diagnostics, equipment, or other such as (but not limited to) [CPT] 94660, 95805, 95806, 95810, 95811 (individually and collectively, the "Service(s)"). PT gives his or her informed consent and authorizes SSDC to confirm, provide, and bill these Service(s). As a courtesy to PT, SSDC will file PT's insurance claim to PT's insurance provider(s) and/or Medicare (collectively, the "Provider") on PT's behalf for these Service(s). PT understands and acknowledges that PT is solely financially responsible (without limitation) for immediately and completely paying any remaining balances, amounts unpaid, or benefits denied in the unexpected event Provider denies the submitted claim(s). PT authorizes his or her Provider benefits be paid to SSDC for Service(s) performed or provided by SSDC and authorizes any holder of medical information about PT be released to SSDC (or any third party responsible) for payment and any information necessary to determine benefits payable or obtain payment for the Service(s) PT receives by or from SSDC. PT agrees to forward to SSDC, without delay, any payment made directly to PT for all such Service(s) provided by SSDC.
SSDC does not assume responsibility for requirements involved with any PT insurance(s) or related claim(s). PT must provide to SSDC all insurance information necessary to file and complete PT’s insurance(s) claim(s). PT must immediately notify SSDC of any change or loss of your insurance(s) and related coverage(s) during the term of this Agreement. PT must pay all amounts due under this Agreement (without limit including related deductibles and coinsurances). PT must pay any outstanding balances remaining after any secondary insurance(s) is filed (if applicable). SSDC does not guarantee coverage(s) or payment by any insurances and/or involving any related insurance(s) claim(s). PT is responsible for payment in full involving all claims not covered or that SSDC is not paid for by PT’s insurance(s) in accordance with SSDC Written Quote to PT. SSDC cannot and does not guarantee any time frame involving the processing of PT’s insurance(s) or subsequent billing(s) by SSDC. Assignment of benefits of third-party does not relieve PT's obligation to ensure full payment under this Agreement. SSDC does not offer billing of tertiary payers, but SSDC will provide documentation for PT to submit related insurance(s) claim(s) on his/her own.
PT represents and warrants that said PT signatures bearing PT's name are made by PT and that PT is legally competent to execute this Agreement between PT and SSDC or the duly authorized representative of PT is legally authorized to execute this Agreement on PT's behalf. PT acknowledges that SSDC has not assessed PT’s home environment and therefore assumes no responsibility for the safety of any procedures or equipment sent home with PT to the home environment or PT’s usage of any procedures or equipment within PT’s home environment or anywhere else PT may travel to or use said procedures or equipment. PT is solely responsible for all legal, medical, financial, and other responsibilities, laws, regulations, and other contemplating the proper, safe, and legal use of all procedures and equipment.
PT authorizes SSDC to provide, at PT’s ordering or treating healthcare provider’s direction, these Service(s). PT agree that SSDC and its affiliates, agents, or assigns, shall not be liable for any acts or omissions related to the Service(s) provided by SSDC, in accordance with PT’s ordering or treating healthcare provider's orders.
PT requests that payment of authorized healthcare benefits be made on PT’s behalf directly to SSDC for Service(s) provided by SSDC. PT authorizes and assigns directly to SSDC all payments and benefits otherwise payable or available to or involving PT, or to which PT is otherwise entitled, under or pursuant to terms of any government, private, employer, group, or other health insurance program or plan. PT authorizes photocopies of this Agreement to be considered as valid as the original.
PT agree, acknowledge, and accept that PT is obligated to personally pay, in full and immediately upon receipt of bill, the difference between the amounts PT’s insurance benefits or insurance coverage pays to SSDC and what SSDC can lawfully charge for Service(s) provided by SSDC and according to SSDC Written Quote to PT. In the event that SSDC notifies PT that any claims for payment on PT’s behalf were refused by a third party payer for any reason (including, but not limited to, PT’s failure to qualify for Service(s) and/or related services by SSDC, lack of coverage by PT’s insurance payer, or PT failure to provide complete and accurate information needed to bill and be paid by said insurances and/or payer), then PT will immediately upon the billing and/or after submission of statement or demand by SSDC submit full payment to SSDC for Service(s) provided by SSDC under this Agreement. PT payment shall be made to SSDC immediately upon receipt of said billing, statement or demand and shall not exceed fifteen (15) days from receipt of said billing, statement or demand. Deductibles and coinsurance payments under private third party insurances and/or contracts generally are due at or before SSDC furnishes Service(s). In the event SSDC does not collect these payments from PT up front in advance of Service(s), PT agree that PT is and will continue to be obligated to make all such deductible or coinsurance or copayment payments immediately upon receipt of said billing, statement or demand and shall not exceed thirty (30) days from receipt of said billing, statement or demand. PT agrees and acknowledges that SSDC may refuse further, other or added Service(s) to PT or on PT’s behalf until any and/or all such payment(s) is made in full and may decline to produce medical records or documentation until all payments are made (as permitted by law). PT agrees and acknowledges that failure to remit full repayment within forty-five (45) days to SSDC of all monies due by PT to SSDC will be deemed in default. PT agrees and acknowledges that SSDC may use all commercial options available for seeking repayment within sixty (60) days of all such payments due, which may include the use of third-party collection agencies and collection of Service(s) (where applicable). SSDC will not be liable for the disclosure of PT's protected information including PT’s protected health information to said third-party companies used for obtaining repayment nor any related medical costs or treatment interruptions PT may incur (and the related health risks to untreated sleep disorders) due to said Service(s) discontinuation.
DISCLAIMER OF WARRANTIES / LIMITATION OF LIABILITIES: EXCEPT WHERE STATED OTHERWISE, SSDC MAKES NO EXPRESS OR IMPLIED REPRESENTATION OR WARRANTIES CONCERNING SERVICE(S) PROVIDED AND DISCLAIMS, WITHOUT LIMITATION, ANY IMPLIED WARRANTY OF MERCHANTIABILITY OR FITNESS FOR A PARTICULAR PURPOSE, TO THE EXTENT ALLOWED BY APPLICABLE LAW. MOREOVER, SSDC SHALL NOT BE RESPONSIBLE FOR ANY SPECIAL, INCIDENTAL, OR CONSEQUENTIAL DAMAGES CAUSED BY SERVICE(S) PROVIDED BY SSDC, EVEN IF SSDC HAS KNOWLEDGE OF THE POSSIBILITY OF SUCH POTENTIAL LOSS OR DAMAGE.
SSDC will perform Service(s) in accordance with the ordering or treating healthcare provider's orders and standards published by the American Academy of Sleep Medicine (AASM), the Centers for Disease Control (CDC), the Centers for Medicare Services (CMS), the interpreting physician, and the SSDC Medical Director (when applicable).
PT understands that if PT has questions or concerns regarding PT's insurance coverage(s) or payments due or the Service(s), PT must contact SSDC during daytime administrative hours prior to the scheduled Service(s). PT agrees to promptly pay all such payments due from PT to SSDC not later than the date of PT's Service(s) unless prior financial arrangements have been established and approved by SSDC.
Member Authorization Form for a Designated Representative to Appeal a Determination
I HEREBY AUTHORIZE SleepSomatics [together, doing business as SleepSomatics or SleepSomatics Diagnostic Center, SleepSomatics LP (TIN 20-4601197 NPI 1538251202) and EL’Lucre Management Corp (TIN 52-2416115 NPI 1013191386)] whose physical location is 2211 W Parmer Ln, Ste A, Austin, TX, 78727 and whose telephone number is (512) 323-9253 and whose fax is (512) 323-9254 (individually and collectively, "SSDC") for the purposes stated herein (collectively, the "Agreement") TO APPEAL INSURER'S DETERMINATION CONCERNING my ordering or treating healthcare provider-ordered sleep diagnostic appointment which may include procedures, diagnostics, equipment, or other such as (but not limited to) 94660, 95805, 95806, 95810, 95811 (individually and collectively, the "Service(s)") on my behalf, as my Designated Representative, and, as part of the appeal, I hereby authorize all of my INSURANCE'S in any related decision letter and in connection with the processing of any necessary appeal(s), to communicate with my Designated Representative in all aspects of such appeal(s).
I understand these communications may contain the following: All medical and financial information contained in my insurance file involving SleepSomatics [together, doing business as SleepSomatics or SleepSomatics Diagnostic Center, SleepSomatics LP (TIN 20-4601197 NPI 1538251202) and EL’Lucre Management Corp (TIN 52-2416115 NPI 1013191386)] whose physical location is 2211 W Parmer Ln, Ste A, Austin, TX, 78727 and whose telephone number is (512) 323-9253 and whose fax is (512) 323-9254 (individually and collectively, "SSDC") for the purposes stated herein (collectively, the "Agreement") including and relating to my ordering or treating healthcare provider-ordered sleep diagnostic appointment which may include procedures, diagnostics, equipment, or other such as (but not limited to) 94660, 95805, 95806, 95810, 95811 (individually and collectively, the "Service(s)") in connection with and in the case of any such determination which is being appealed.
I understand this information is privileged and confidential and will only be released as specified in this authorization, or as required or permitted by law. This authorization is valid for a period of three years, or the time it takes for SleepSomatics [together, doing business as SleepSomatics or SleepSomatics Diagnostic Center, SleepSomatics LP (TIN 20-4601197 NPI 1538251202) and EL’Lucre Management Corp (TIN 52-2416115 NPI 1013191386)] whose physical location is 2211 W Parmer Ln, Ste A, Austin, TX, 78727 and whose telephone number is (512) 323-9253 and whose fax is (512) 323-9254 (individually and collectively, "SSDC") for the purposes stated herein (collectively, the "Agreement") to appeal for correct payment under my Insurance Plan(s).
SSDC Additional Disclosures
PT is solely responsible for notifying SSDC in writing of changes to his/her contact information, with said notification being delivered to and received by SSDC. SSDC is not responsible for locating PT in the case s/he provided incorrect contact information in this Agreement or whose contact information changed after this Agreement’s execution.
PT is responsible for supplying SSDC with needed insurance information necessary to obtain payment for services, equipment, supplies, and/or accessories. PT is responsible for assuming sole and full responsibility for all charges and costs not covered by PT’s insurance(s), including deductibles and coinsurances. PT is fully 100% responsible for settlement in full of any outstanding balances under this Agreement.
PT is responsible for contacting SSDC by telephone at (512) 323-9253 to schedule, modify, or cancel appointments and acknowledges and understands that there may be additional fees for “no-shows” or same-day cancellations for procedures, diagnostics, and confirmed appointments.
PT is responsible for immediately notifying SSDC by telephone at (512) 323-9253 if PT has: any change in PT’s physician’s prescription; any change or loss in insurance(s) or related coverage(s); any change in PT's contact information, whether permanent or temporary; any infectious diseases or illness PT has or may suspect s/he have prior to or during PT’s time of service.
SSDC offers flexible appointment times and schedules. SSDC does not offer walk-in services. All SSDC services are available by appointment only. Appointment availability is limited based upon a first-come, first-serve basis. SSDC makes no guarantee as to appointment availability.
PT has the right to considerate and respectful service and to obtain service without regard to race, creed, national origin, gender, age, sexual orientation, disability, illness, veteran status, religious affiliation, or any other protected class under the law. SSDC reserves the right to refuse Service(s) to anyone if deemed necessary by SSDC at its sole discretion. SSDC reserves the right to refuse Service(s) to anyone if SSDC deems necessary, at its sole discretion, that PT requires Service(s) that SSDC is unable to adequately provide. PT has the right to confidentiality of all information pertaining to PT’s medical care and service. PT has the right to a timely response to his/her request for service (depending upon the service requested). PT has the right to select another provider of his/her choice and to make informed decisions regarding PT’s care including the right to agree or to refuse any part of the PT’s plan of service or plan of care. PT has the right to be told what service will be provided, how, and to voice grievances.
SSDC observes thorough PT grievance and complaint procedures to effectively resolve problems that may arise. Any PT that has a concern, may call SSDC by telephone at (512) 323-9253, or may write to SSDC.
SSDC Consent for Use and Disclosure of PT Health Information – HIPAA and Privacy Notice
SSDC may employ any or all of the following options to contact PT: telephone calls, voicemail messages, postcards or letters via postal mailings, SMS text messages, and/or emails. PT gives SSDC authorization and permission and directs SSDC to leave PT messages when attempting to contact PT at the phone number(s), email addresses, postal mailing addresses, and any and all other contact options provided by PT to SSDC. These messages may or may not contain HIPAA-protected private information regarding procedures, diagnostics, tests, appointments, insurance, or other. These messages may be left on voicemail (cell, home, work, etc.), by text message, by email, or other. PT releases SSDC from any and all liability arising out of or resulting from someone else overhearing or in some way intercepting messages left by SSDC for PT. PT will notify SSDC if there is contact information or methods PT does not want used by SSDC when attempting to contact PT. PT has the option to decline one or all of the above listed communication methods by evidencing their choice with a letter signed by PT and delivered or mailed to SSDC.
PT consents to SSDC using and disclosing his/her protected information or PT’s protected health information in order to provide Service(s), to collect payment, and to care for PT’s health. This may include (but shall not be limited to) disclosure of PT’s protected health information to third-party companies for the purpose of collection of payments or monies owed, including but not limited to PT insurances, banks or credit card companies, third-party collection agencies, and/or credit reporting agencies.
A copy of the SSDC Privacy Notice and Patient Bill of Rights may be found and printed from SSDC's website at www.sleepsomatics.com. These notices provide a detailed description of how SSDC may use PT protect information or PT’s protected health information. PT has the right to abstain from signing this consent until s/he has read these notices. PT has the right to refuse to sign this consent. Such refusal may mean that SSDC may decline to treat PT, or to continue treating PT. SSDC reserves the right to change our privacy practices as described in our Privacy Notice.
If PT’s household situation changes, it is his/her responsibility to file a new Communication Authorization with SSDC. If s/he fail to notify SSDC, we are not responsible for unwanted communications. The permissions PT give on this form will be considered current until PT file a newer form with SSDC. PT has the right to revoke this consent at any time. To do so s/he must deliver or mail written notice of their revocation to SSDC. Revocation of this consent will not apply retroactively. Revoking this consent may mean that SSDC may decline to treat PT, or to continue treating PT.
SSDC Authorization to Release PT Medical Records
PT hereby authorizes the use or disclosure of PT reports, charts, data, and other information from the diagnostic and health records received, created, compiled, or otherwise in the possession of or resulting from or in connection with other physician-ordered diagnostic sleep study or studies with other diagnostic providers, physicians, or DME companies (collectively, the "Record"). PT direct his/her Record to be immediately furnished to SSDC as required by SSDC to complete the Service(s) or fulfill any orders or directives made by PT’s physician as part of PT’s treatment. PT understands that his/her Record may only be released at PT’s specific direction, and PT directs such release to SSDC. Any other use of this information without PT’s written consent is prohibited.
PT understands that PT has a right to revoke this authorization at any time. PT understands that if PT revokes this authorization, PT must do so in writing and present his/her written revocation to the individual or organization releasing the information. PT understands that the revocation will not apply to information already released in response to this authorization. PT understands that the revocation will not apply to PT’s insurance company when the law provides PT’s insurer with the right to contest a claim under PT’s policy. Unless otherwise revoked, this authorization shall expire upon completion of this request.
PT understands that authorizing the disclosure of his/her Record is voluntary. PT understands that s/he may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. PT understands that any disclosure of information carries with it the potential for unauthorized re-disclosure and the information may not be protected by federal or state confidentiality or privacy laws. If PT has questions about disclosure of his/her Record, PT can contact SSDC during daytime administrative hours at (512) 323-9253. PT understands that the information in PT’s Record may include information relating to sexually-transmitted diseases, acquired immunodeficiency syndrome (AIDS), human immunodeficiency virus (HIV), behavioral and/or mental health services, and treatment for substance abuse.
PT understands that his/her Record may contain reports, diagnostic and or therapy results, and/or notes that only a physician can interpret or diagnose. PT understands and is advised to contact his/her physician regarding the entries made in PT’s Record to prevent PT misunderstanding of the information contained in his/her Record. PT releases and holds harmless SSDC from any and all liabilities arising out of or resulting from any misinterpretation of the information contained in PT’s Record or as a result of PT not contacting his/her physician for the correct interpretation.