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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:
1. I will be responsible for the full payment of the services rendered.
2. No insurance claims will be submitted on my behalf for the forementioned services.
3. 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.
Authorization for Use and Disclosure of Health Information: 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 CPAP.com, 13235 N Promenade Blvd, Stafford, TX 77477. 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.
Order your home sleep study kit and take back your sleep again!
*SleepMedRx consultations are cash based and not submitted to insurance.
Need a sleep apnea test for work? No insurance? Don't want the hassle of an in-lab sleep study?
Our sleep study test kit is FDA, AASM, DOT, and FAA approved in all 50 US states and can be done in the convenience of your own bed.
CPAP.com is a supplier of CPAP equipment and does not provide medical advice, diagnosis, or treatment. CPAP.com does not control and is not responsible for any care or treatment rendered or not rendered by third parties, including SleepMedRx and its healthcare professionals. This website and any information is not intended and should not be construed as the creation of a physician-patient relationship with or as the practice of medicine.