Sleep Diagnostics
REGISTRATION FORM
Patient Data Information
(Please Print)
Last Name: ______First Name: ______MI: ______
Address: ______
City: ______State: ______Zip: ______Phone: ( ) ______
Occupation: ______Employer:______
Date of Birth: ______M / F_____ Age: _____Social Security# ______
Next of kin to notify in case of emergency: ______
Relationship to patient:______Phone#: ( ) ______
Known drug allergies: ______
Referring Physician: ______
Primary Care Physician: ______
Financial Policy
Co-payments and payments for services not covered by your insurance will be due at your visit. For your convenience, we accept cash, check, debit or credit card (MasterCard, Visa and Discover).
Healthline Diagnostics, Inc. will file your insurance claim for you if you provide all current insurance information including secondary insurance. Your out of pocket amount is based on benefits quoted by your insurance carrier, but not a guarantee of amount owed. After your claim has been processed the amount quoted may be different. You may be responsible for more than quoted. If the amount is less, then you will be given a refund. All health plans are not the same and do not cover the same services. In the event your health plan determines that a service is “not covered”, you will be responsible for the complete charge. Payment is due upon receipt of a statement from our office.
Medicare: We will accept assignment for our Medicare patients. If you do not have a Medicare supplement, we expect you to pay your deductible if not met at the time, as well as your 20 percent.
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Release of Information
I hereby authorize Healthline Diagnostics, Inc. to furnish medical information concerning my sleep study to my family physician(s) referring physician, healthcare providers (DME) and insurance companies. I further authorize my family physician(s) referring physician and other healthcare providers to furnish all medical information concerning my sleep study to Healthline Diagnostics. I hereby authorize my insurance carrier to pay directly to Healthline Diagnostics benefits due to me as provided in my contract for services rendered. I understand that I am personally responsible for charges at the in-network benefits rate for my insurance plan, including in-network co-pays and/or deductibles.
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Consent for Treatment
Consent is given for the placement of all monitoring devices necessary, including audio / video recording to perform this sleep study in accordance with the AASM Clinical Practice Guidelines of Polysomnography and in compliance with the orders of my referring physician. Although continuous monitoring by a trained sleep technician occurs throughout the night, any medical emergency that may arise cannot be anticipated nor prevented. If such an emergency should occur, immediate emergency response by the attending sleep technician in accordance to written emergency protocol guidelines shall be implemented. I hereby authorize evaluation and treatment by Texoma Sleep Diagnostics. ____
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Signature: ______Date:______
(Patient or Parent/Guardian Signature)
Witness Signature: ______Date:______
Healthline Diagnostics, Inc. d.b.a. Texoma Sleep Diagnostics