SleepSomatics Terms of Service

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 “noshows”

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 HIPAAprotected

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 redisclosure

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.