I hereby give my consent for Southeast Regional Sleep Disorders Center (SRSDC) to use and disclose protected health information (PHI) about me to carry out treatment, payment, and health care operations (TPO).

I have the right to review the Notice of Privacy Practices prior to signing this consent.  Southeast Regional Sleep Disorders Center (SRSDC) reserves the right to revise the Notice of Privacy Practices at any time.  A revised Notice of Privacy Practices may be obtained by the forwarding a written request to Southeast Regional Sleep Disorders Center (SRSDC) at 357 Woodruff Road, Greenville, South Carolina 29607.

With this consent, Southeast Regional Sleep Disorders Center (SRSDC) may call my home or alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items, and any calls pertaining to my clinical care, including laboratory test results, among others.

With this consent, Southeast Regional Sleep Disorders Center (SRSDC) may mail to my home or other alternative location any items that assist the facility in carrying out TPO, such as appointment reminders, prescriptions and patient statements.

With this consent, Southeast Regional Sleep Disorders Center (SRSDC) may disclose my PHI to providers not affiliated with Southeast Regional Sleep Disorders Center (SRSDC) to facilitate care provided to me.

By signing this form, I am consenting to allow Southeast Regional Sleep Disorders Center (SRSDC) to use and disclose my PHI to carry out TPO.

I may revoke my consent in writing except to the extent the facility has already made disclosures in reliance upon my prior request.  If I do not sign this consent, or later revoke it, Southeast Regional Sleep Disorders Center (SRSDC) may decline to provide treatment to me.

A.  Release of Information, Assignment, and Authorization to pay Financial Benefits:

The sleep center, my physician or physicians may disclose all or any part of the patient records to any person which is or may be liable for or responsible for payment of all or part of the sleep center and/or physician charges, including, but not limited to, insurance companies, medical or lab service companies, workmen’s compensation carriers, employers, and welfare funds.  I certify that the information given by me in applying for payment under Title XVIII or Title XIX of the Social Security Act is correct.  I authorize any holder of medical or other information about the patient to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a Medicare or Medicaid claim.  In consideration of Southeast Regional Sleep Disorders Center (SRSDC) advancing or extending credit for sleep diagnostic procedures, the undersigned hereby assigns and transfers to Southeast Regional Sleep Disorders Center (SRSDC) all benefits and payment now due and payable or to become due and payable to the patient under any insurance policy or policies, under any replacement policies thereof, under any self insurance program, worker compensation policy or program, employers and state welfare funds, or under any other benefit plan, for this period of care.  I request that payment of authorized benefits be made on behalf of the patient directly to the said physician, physicians, and sleep center and to any appropriate agents or divisions.

B.  Release of Medical Information:

The undersigned agrees to the release of medical information to referral sources to facilitate communication between facilities that have and may provide care and to assist in the discharge process.

C.  Financial Agreement:

The undersigned agrees, whether he or she signs as an agent or as patient, that in consideration of the services to be renders to the patient, the patient is hereby obligated to pay the account of the sleep center in accordance with the regular rates and terms of the physician, physicians and the sleep center.  Should the account be referred to an attorney or collection agency for collection, the patient shall pay actual attorney’s fees, and collections expenses.  All accounts shall bear interest at the regular rates.

D.  Insurance Policy:

I hereby authorize my insurance company to furnish all copies of my insurance policy to the physician or physicians and the sleep center.

I have read and explained the above information and all parts of this form outlining all stated conditions to the patient’s legal representative and the patient/responsible party appears to fully understand these conditions as stated.