Certification of Identity
The patient consents to the fact that they are the person who is attaching the at home sleep testing device to their body. On date of purchase, the patient certifies that they understand it would be fraudulent to claim the patient was taking the test when it was actually taken by another person on their behalf.
The patient also agrees that no one else will have possession of the MHSleepTestingTM device while it is in the patient’s care, and the test is therefore an accurate interpretation of the patients sleep patterns.
Acknowledgement of receipt is in effect on date of purchase.
Consent for Treatment
The patient hereby authorizes MHSleepTestingTM and its affiliated physicians and other medical personnel in charge of my care to conduct medical interview, administer examinations, counseling and treatments in person, over the phone, or over the internet, as may be deemed medically necessary in the exercise of their professional judgment.
Acknowledgement of receipt is in effect on date of purchase.
MHSleepTestingTM Machine Return Policy
The MHSleepTestingTM machines are very popular. Therefore, it is important that you return your machine within the specified amount of time, two nights after receiving machine, so that the next patient may get tested.
To give the patient adequate time to take the test, the patient may keep the MHSleepTestingTM machine for two nights (48 hours). It is important the patient understands that the machine needs to be returned after that second night (48 hours). To schedule a pick-up, you must call UPS by midnight the previous night at (800) 742-5877 or schedule a pick-up online at www.UPS.com.
Machines not mailed within 48 hours of their receipt will be subject to a $20 per day charge to their purchased credit card until machine is picked up/dropped off with UPS.
By purchasing the use of our PST machine, the patient accepts and understands this policy. The patient will make every effort to return the machine within 48 hours so we can get the patient the test results within the five-business day timeframe.
Acknowledgement of receipt is in effect on date of purchase.
MHSLEEPTESTINGTM NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU MAY GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY.
MHSleepTestingTM is dedicated to protecting your medical information. We are required by law to maintain the privacy of protected health information and to provide you with this Notice of our legal duties and privacy practices with respect to protected health information. MHSleepTestingTM is required by law to abide by the terms of this Notice.
HOW YOUR MEDICAL INFORMATION WILL BE USED AND DISCLOSED:
The following describes how MHSleepTestingTM may use your protected health information for treatment, payment or health care operations.
Treatment:
MHSleepTestingTM may use health information about you to provide you with health care treatment or services. MHSleepTestingTM may disclose health information about you to doctors, nurses, or other essential personnel who are involved in your care. For example, our office may disclose health information about you to a specialist who has been asked to provide a consultation regarding your care.
Payment:
MHSleepTestingTM may use and disclose health information about you to receive payment for services provided to you. For example, our office may disclose certain information to our health insurance provider in order to receive payment for services provided to you. Under Florida law we must obtain your written consent in order to submit claims for services provided to you. While we do not condition treatment on your signing of our general consent form, failure to sign may force us to decline you as a new patient or discontinue you as an active patient.
Health Care Operations:
MHSleepTestingTM may use and disclose health information about you for operational purposes related to our office. These uses and disclosures are necessary to run our office and make sure that all of our patients receive quality care. For example, MHSleepTestingTM may use your protected health information in our peer review activities. Such activities are confidential and are designed to assist our office in maintaining a high standard of medical care. We may also use and/or disclose your information in accordance with federal and state laws for the
following purposes:
Appointments Reminders.
We may contact you to provide appointment reminders.
Treatment Information:
We may contact you with information about treatment alternatives or other health related benefits and services that may be of interests to you.
Disclosure to Department of Health and Human Services:
We may disclose medical information when required by the United States Department of Health and Human Services as part of an investigation or determination of our compliance with relevant laws.
Family and Friends:
Unless you object, we may disclose your medical information to immediate family members or other relatives or close personal friends as authorized by you, when the medical information is directly relevant to that person’s involvement with your care.
Notification:
Unless you object, we may use or disclose your medical information to notify a family member, a personal representative or another person responsible for your care of your location, general condition or death.
Disaster Relief:
We may disclose your medical information to a public entity, such as the American Red Cross, for the purpose or coordinating with that entity to assist in disaster relief efforts.
Health Oversight Activities:
We may disclose your medical information to a health oversight agency for oversight activities authorized by law, including audits, investigations, inspections, licensure or disciplinary actions, administrative and/or legal proceedings.
Abuse or Neglect:
We may disclose your medical information when it concerns abuse, neglect or violence to you in accordance with federal and state law.
Judicial and Administrative Proceedings:
We may disclose your medical information in the course of certain judicial or administrative proceedings and as required by law.
Law Enforcement:
We may disclose your medical information for certain law enforcement purposes as required by law.
Specialized Government Functions:
We may disclose medical information as required by law for certain specialized government functions including: certain military and veterans activities, national security and intelligence activities, protective services for the President and others, and correctional institution and law enforcement custodial situations.
Coroners, Medical Examiner’s and Funerals Directors:
We may disclose your medical information to a coroner, medical examiner or a funeral director.
Organ Donation:
If you are an organ donor, we may disclose your medical information to an organ donation and procurement organization.
Research:
We may use or disclose your medical information for certain research purposes if an Institutional authorization, the review is preparatory to research or the research is on only decedent’s information.
Public Health Activities:
We may use or disclose your medical information for public health activities, including the reporting of disease, injury, vital events and the conduct of public health surveillance, investigation and/or intervention.
Public Safety:
We may use or disclose your medical information to prevent or lessen a serious threat to the health or safety of another person or to the public.
Worker’s compensation:
We may disclose your medical information as authorized by laws relating to workers compensation or similar programs.
Business Associates:
We may disclose your health information to a business with whom we contact to provide services on our behalf. To protect your health information, we require our business associates with whom we contact to provide services on our behalf. To protect your health information, we require our business associates to appropriately safeguard the health information of our patients.
MINIMUM NECESSARY INCIDENTAL DISCLOSURES AND SUPER CONFIDENTIAL INFORMATION
Our staff will not use or disclose your medical information unless it is necessary to perform their jobs. In other words, access to your medical information will be based on a need to know circumstance. When your medical or payment information is disclosed, only the necessary amount of medical or other information needed to accomplish the recipients lawful purpose will be disclosed. Additionally, while using or disclosing your confidential information we will take every reasonable step to prevent such information from being inadvertently disclosed. Finally, we will follow both state and federal laws related to the use and disclosure of super-confidential information such as HIV/AIDS, alcohol/substance abuse and mental health records.
AUTHORIZATIONS and CONSENTS:
We will not use or disclose your medical information for any other purpose other than treatment, payment or health care operations without your written authorization. Once given, you may revoke your authorization in writing at any time. To request a Revocation of Authorization form you may contact the office’s Privacy Contact, or office manager. Additionally, the time of your first office visit you will be asked to sign a general consent/records release. This consent is required under Florida law in order for our office to submit claims and other information needed to receive for services rendered to you or your family.
YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION:
You have the following rights with respect to your medial information:
You may ask us to restrict certain uses and disclosures for your medical information. We are not required to agree to your request, but if we do we will honor it.
You have the right to receive communications from us in a confidential manner.
Generally, you may inspect and copy your medical information. This right is subject to certain specific exceptions, and you may be charged a reasonable fee for any copies of your records.
You may ask us to amend your medical information. We may deny your request for certain specific reasons. If we deny request, we will provide you with a written explanation for the denial and information regarding further rights you may have at that point.
You have the right to receive an accounting of the disclosures of your medical information made by MHSleepTestingTM during the last 6 yrs. Except for disclosures for treatment, payment or healthcare operations, disclosures which you authorized and certain other specific disclosure types.
You have the right to complain to us and/or to the United States Department of Health and Human Services if you believe that we have violated your privacy rights. If you choose to file a complaint, you will not be retaliated against in any way. To complain to us, please require at the Registration desk (you will be directed to our Privacy Officer).
To file a complaint with the U.S. Department of Health and Human Services you must submit your complaint in writing, within 180 days of the alleged violation to:
Region I.V, Office for Civil Rights
U.S. Department of Health and Human Services
Atlanta Federal Center, Suite 3B70
61 Forsyth Street, S.W
Atlanta, GA 30303-8909
Voice phone 404-562-7886
We are required by law to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your health information.
Acknowledgement of receipt is in effect on date of purchase.
Patient Financial Responsibility
1. All patients or guardians are responsible for 100% of the charges incurred for treatment.
2. The patient or guardian agrees to terms and conditions and the financial policy statement is the responsible party.
3. Patients may pay their bills using PayPal or credit card.
4. A $20.00 per day surcharge will apply if the MHSleepTestingTM machine is not returned after 48 hours of patient possession. Please follow our return policy to avoid these surcharges, this is personally liable to the patient or guardian.
5. Patients who fail to pay their outstanding balance within 60 days of the date of machine arrival to patient may be turned over to a collection agency. The patient will still be responsible for the charges as well as all collection agency costs and fees, including reasonable attorney fees.
MHSleepTestingTM has developed these financial policies in an effort to keep the patient’s medical costs down. Printing and mailing statements is an extremely time consuming and expensive undertaking. MHSleepTestingTM asks that the patient adheres to these policies as part of the patient’s financial responsibility. The staff at MHSleepTestingTM will assist the patient in any way. If the patient has questions regarding the fees, please ask to speak with one of the team members of the billing department.
