I hereby consent to using live telemedicine services provided by Pacific Sleep Program. I understand that telemedicine services are conducted through an interactive audio and video connection which allows my provider to consult with me about my medical condition. I understand that these services may involve the communication of my health information, both orally and visually, to my provider.
I further understand the following with respect to Pacific Sleep Program’s telemedicine services:
For sleep studies, (either at home or in lab) and PAP application, the most likely and most serious risks of the procedure include, but are not limited to:
I am aware that there may be other risks or complications not discussed that may occur. I also understand that during the course of the proposed procedure, unforeseen conditions may be revealed requiring the performance of additional procedures, and I authorize such procedures to be performed. I acknowledge that no guarantees or promises have been made to me concerning the results of this procedure or any treatment that may be required as a result of this procedure.
If I take a sleep aid before or during a sleep study, I am aware that sedatives such as diphenhydramine(Benadryl), doxylamine (Unisom), trazodone, Ambien (zolpidem), Sonata (zaleplon) and other sleep aids may impair my thinking and reaction time. I understand that I may feel drowsy in the morning after taking a sleep aid.I understand that Pacific Sleep Program strongly recommends that I wait at least 7 hours or until I am fully awake before I do any type of activity that requires me to be awake and alert. If I am unable to safely operate a motor vehicle, I understand that I must have a ride home available in the morning or, if day staffing is available the next day, I will remain in the clinic until I am able to safely operate a motor Pangiot vehicle or will contact someone to drive me home.If I decide to terminate my study, I acknowledge that I am refusing at my own insistence and without theauthority of and against the advice of the facility, requesting to leave against medical advice and Ihereby release Pacific Sleep Program from any responsibility for all consequences which may result fromthe use of a sleep aid during the study or from leaving against medical advice.
Please contact your pharmacy for prescription refills. Medication refill request may take up to 5-7business days to process. Prescriptions will be handled Monday through Thursday, 8:00 AM-4:30 PM. There will be no refills after hours or on the weekends so please plan accordingly.
Pacific Sleep Program will only authorize refills on medications prescribed by Pacific Sleep Program providers. Medications prescribed by other providers will not be refilled by Pacific Sleep Program.Pacific Sleep Program will notify you if the prescription has been denied or there is a need for a followup visit prior to refilling your medication. Keep in mind that controlled substances require signedprescriptions by law and cannot be refilled without an office visit.
Controlled substances are those that are closely controlled by local, state, and federal government.
I understand that the long-term use of such substances as sedatives (Ambien, Lunesta), benzodiazepines(Xanax, Klonopin), and stimulants (Adderall, Ritalin) is controversial because it is not certain whether they help patients over the long-term. Patients who are prescribed these drugs have some risk of developing an addictive disorder or suffering a relapse of a prior addiction. The extent of this risk is not certain.
I understand that dependence is not the same as addiction. Many people who take controlled substances daily will become dependent on them. Dependence is when your body adapts to the medication and then experiences withdrawal if the medication is stopped or lowered too quickly. Withdrawal symptoms can include moodiness, ache, and pains, sweating, diarrhea, abdominal pain and even seizures.
I understand that addiction is not the same as dependence. While many people become dependent on daily opioids, only a small percentage of these people will become addicted. Addiction is characterized by behaviors such as loss of control of drug use, compulsive use, and craving, and continued use despite harm or risk to the person.
I understand that if I am prescribed controlled substances, I should not increase the dose or stop the medication unless asked to do so by their provider or their covering associate.I understand that I must follow through on appointments and other non-medication recommendations.These may include counseling and other mental health practices and use of positive airway pressure.Consistent failure to keep these appointments and therapies may result in the stopping of the controlled substance medications or possibly discharge from the practice. No refills will be given during holidays, at night or on weekends.
I understand that early refills will not be given unless approved by my provider.
I understand that I will not tamper with or change a written prescription and understand that is a felony to do so.
I understand I will not share, exchange, or sell my controlled substance medications, as the law prohibits those actions. I understand that my provider will report serious concerns of drug misuse to authorities for investigation.
I understand that I take another person’s-controlled substance (prescribed either by Pacific SleepProgram or another providers office), I will be discharged from Pacific Sleep Program and may be reported to the authorities for investigation.
I understand I will not use illegal/street drugs when using controlled substance prescribed by PacificSleep Program. Patient will not use other controlled substance medications for sleep unless prescribed by the provider.
I agree to provide samples for random drug testing when asked. If I fail to provide the sample when asked or is the results are unsatisfactory, I may forfeit the right to continue receiving the medication and possibly be discharged from the practice.
If my provider is concerned that I might have a substance abuse problem, I must agree to an evaluation by a specialist in abuse/addiction. If the evaluation suggests I have a drug abuse problem, my provider may stop my medication in a way that does not cause withdrawal symptoms.
I recognize that controlled substances by themselves, in combination with alcohol or in combination with other medications can result in unclear thinking and loss of coordination. I agree to contact my provider if these symptoms arise. I should not drive or operate equipment if I have these side effects.
It is my responsibility to keep my medication safe. If controlled substance medications are lost, damaged or stolen, the medication may or may not be refilled early. Each case will be looked at individually. If the medication is stolen, I must file a police report and submit the number for verification to my provider’s office. Again, stolen medications may or may not be refilled. If a refill is given, it will be given only once.
As a courtesy to you, our office will bill your insurance company on your behalf for services rendered, provided complete and accurate information is provided at the time of each visit.
I certify the information given by me is correct and I have read and consent to the terms of the financial agreement. I certify that I am the patient or am otherwise authorized to execute this document and accept its terms on behalf of the patient. I assume individually all financial responsibility by signing this form.
By signing below, I (Patient or Authorized Consenter) hereby acknowledge I have read and fully understand the above information. I have asked questions about anything not clear to me and am satisfied with the answers I have received. I understand that I may revoke my consent or authorization at any time except to the extent that action has been taken in reliance on such consent or authorization
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