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.
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