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.
Controlled substances are those that are closely controlled by local, state, and federal government.
Pacific Sleep Program is a Center of Excellence for Inspire Sleep Apnea Therapy and follows all recommended care pathways. I understand that the Inspire neurostimulator therapy's effectiveness depends on consistent use of the device as prescribed and adherence to the follow-up schedule and treatment of concurrent sleep disorders. Non-compliance with the treatment plan may result in reduced efficacy or complications and is not the responsibility of Pacific Sleep Program. Use of Inspire therapy requires:
While we strive to maintain a professional and supportive relationship with all patients, there are instances where it may no longer be appropriate to continue the physician-patient relationship. This includes repeated non-compliance with treatment, missed appointments, defamatory actions against the practice or behavior that is disruptive, disrespectful, or otherwise intolerable to staff or to other patients. Such conduct can severely impact on the quality of care provided and will be grounds for termination from the practice.
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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