Prescription Required
Are you 22 years of age or older?
Unfortunately, the NightOwl® home sleep test device has certain age restrictions for its use. You must be 22 years of age and older.
I authorize the third party healthcare professional (“HCP”) and telehealth service providers involved in the home sleep test services (“HST”), including SleepMedRx, DocViaWeb (collectively, “Telehealth Providers”), to disclose my health and personal information (including contact information and prescription, if one is issued) to CPAP.com. I further authorize CPAP.com to contact me regarding product fulfillment, if a prescription is issued, and to disclose sleep data and other product or device information in connection with the HST to the Telehealth Providers, including for follow up appointments or visits.The purpose of these disclosures is to coordinate and facilitate care and the provision of healthcare items and services to me, which may constitute marketing purposes.
Effective Time Period/Right to Revoke: This authorization is valid for one year after the purchase of any HST, including any follow up appointments or services. I can withdraw my authorization at any time by giving written notice stating my intent to revoke this authorization to CPAP.com by sending written notice to [insert contact information]. Prior actions taken in reliance on this authorization by persons that had permission to access and disclose my health information will not be affected. I can receive a copy of this authorization by contacting the person identified above.
Information Subject to Re-Disclosure: Information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient (if permitted or required by state law) and may no longer be protected by federal and state privacy laws.
No Denial of Treatment: I have the right to select my healthcare provider and supplier, and I am not obligated or required to use, receive, or purchase any items or services from CPAP.com. If I do not wish to authorize the disclosures described above, I can seek care directly from the Telehealth Providers, or another healthcare professional, and not through CPAP.com. Failure to agree to this authorization may result in not receiving the HST through this site. Except for the HST purchased in connection with this site, treatment, payment, enrollment or eligibility for benefits may not be conditioned on whether I agree to this authorization..
Acknowledgement of Self-Pay Status: I acknowledge that SleepMedRx LLC is a "Cash Pay" practice that is not enrolled in Medicare, or any insurance plans.
By consenting to this purchase, I am opting to pay for the medical services received in cash and do not wish to utilize insurance coverage for the specified treatment or consultation.
I understand that by choosing to be treated by SleepMedRx LLC and receive cash pay
services:
- I will be responsible for the full payment of the services rendered.
- No insurance claims will be submitted on my behalf for the forementioned services.
- I will not be eligible for any reimbursement from my insurance provider for these services.
I further acknowledge that I have received a good faith estimate of the services being provided to me. I understand that any additional services rendered will be invoiced, and I will be responsible for the full payment of those services. I confirm that I have read, understood, and agree to the terms outlined in this acknowledgment.
Transcend Micro Auto Travel CPAP Machine
Transcend Micro Auto Travel CPAP Machine
CPAP Prescription Renewal Service
Home Sleep Apnea Test
AirFit P10 Nasal Pillow Mask
AirFit F20 Full Face Mask
AirFit N20 Nasal Mask
ComfortGel Blue Nasal CPAP Mask
AirFit N30i Nasal Mask
AirTouch F20 Full Face CPAP Mask
AirFit P30i Nasal Pillow CPAP Mask
ResMed Swift FX Nasal Pillow CPAP Mask with Headgear
Mirage Quattro Full Face CPAP Mask
DreamWear Nasal CPAP Mask with Headgear
AirFit F30i Full Face Mask
Amara View Full Face CPAP Mask with Headgear
Mirage FX Nasal CPAP Mask
AirFit F10 Full Face Mask
ResMed AirTouch N20 Nasal CPAP Mask with Headgear
Fisher & Paykel Simplus Full Face CPAP Mask
Philips Respironics Wisp Nasal CPAP Mask
ResMed AirFit F30 Full Face CPAP Mask
Nuance & Nuance Pro Nasal Pillow CPAP Mask with Gel Nasal Pillows
Brevida Nasal Pillow CPAP Mask
Mirage Activa LT Nasal CPAP Mask
ResMed Quattro FX Full Face CPAP Mask
DreamWear Full Face CPAP Mask with Headgear
TAP PAP Nasal Pillow CPAP Mask with Improved Stability Mouthpiece
ResMed AirFit N30 Nasal CPAP Mask
FitLife Total Face CPAP Mask with Headgear
Quattro Air Full Face Mask
ResMed AirFit F40 Full Face CPAP Mask with Headgear
Fisher & Paykel Vitera Full Face Mask
Evora Full Face Mask with Headgear
AirMini Mask Setup Pack with AirFit N30 Nasal CPAP Mask
Hybrid Full Face CPAP Mask with Nasal Pillows and Headgear
SleepWeaver Advance Nasal CPAP Mask with Improved Zzzephyr Seal
Swift FX Nasal Pillow CPAP Mask Assembly Kit
SleepWeaver Elan Soft Cloth Nasal CPAP Mask
Fisher & Paykel Evora Nasal CPAP Mask with Headgear
DreamWisp Nasal CPAP Mask
Oracle HC452 Oral CPAP Mask
Eson Nasal CPAP Mask
FlexiFit HC407 Nasal CPAP Mask
AirMini Mask Setup Pack with AirFit P10 Nasal Pillow CPAP Mask
Fisher & Paykel Solo Nasal Mask
Opus 360 Nasal Pillow CPAP Mask
Bleep DreamPort CPAP Mask Solution
Eson 2 Nasal CPAP Mask
AirTouch N30i Nasal CPAP Mask
FlexiFit HC431 Full Face CPAP Mask
FlexiFit HC432 Full Face CPAP Mask
Simplus Full Face Mask + 2 Cushions
Amara Full Face CPAP Mask with Headgear
The world's smallest sleep therapy solution
