In Home Sleep Testing ~ We Come To You! Welcome and Thank You!

Transcription

1 In Home Sleep Testing ~ We Come To You! Welcome and Thank You! Welcome and Thank you for choosing 1 Stop CPAP Shop, LLC for your In Home Sleep Testing! If at any time you have a question or concern please call (888) ext. 1, 24 hours a day / 7 days a week to speak to a technician. If necessary, please leave a message, include your phone number and a technician will call you right back. Also, if you have received this kit in the mail, please call Patient Service at (888) ext. 1 and let us know you have received it, so we can anticipate the return date. It is our privilege to provide you with the most advanced HST (Home Sleep Test) on the market today, to aid in your diagnosis and treatment of OSA (Obstructive Sleep Apnea). Home Sleep Test Kit and Instructions: HST Device - Alice NightOne Device to be used when you Sleep and Nap. HST Sleep Questionnaire - Completed and Returned with kit. Health Care Providers list you wish to receive your test results - Complete and Return with kit. User and Quick Start Guides Instructions for patient review Return With Kit. Instructional Video 3 Minute Patient Instruction Video at: Plastic Storage Bag Place Device in this bag when testing is complete. HST Device AA Batteries. Change between each use, Return with kit. Financial Responsibility Form, Insurance Gap Notice, and Tentative Return Date Agreement. Tentative Return/Pick up Date: and Time: Patient Instruction Acknowledgement Form Sign and Return with kit. If Mailing: Prepaid Self Addressed Stamped Return Package. Our Toll Free 24/7 Patient Service Number: ext. 1 Once you have received this HST kit, take a minute to measure your neck and complete the questionnaire. Watch the Instructional Video on our website and follow the easy direction for you In home Sleep Test. If you have any questions please call our Toll Free Patient Service Number: ext. 1. If it is after regular business hours, please leave a message with your phone number and a Home Sleep Test Technician will call you right back. After each 7 hour use, the device will automatically shut off. When testing is complete, repackage everything into the kit and return to SMS. Your test results will be available in about 10 business days. We will be happy to assist you and your Heath Care Providers with any needed treatment or therapy. Thank you again and we look forward to your test results. Sleep well! 8128 E. Florentine Rd., Prescott Valley AZ ~ Tel.: (888) ~ Fax: (877) sms.patientservices@gmail.com ~

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3 In Home Sleep Testing ~ We Come To You! Healthcare Provider List ~ Return With Device Hello and Thank you again for choosing 1 Stop CPAP Shop, LLC for your In Home Sleep Testing! In effort to provide the quickest results of your HST (Home Sleep Test) to your pertinent Health Care Provides (HCP); please provide us the Correct Name, City and Phone Number of each of your HCP listed below. This will allow all your HCP to be aware of your testing, diagnosis and any treatment plan. This will also allow 1 Stop CPAP Shop, LLC an opportunity to reach out to the providers whom may not otherwise know of our revolutionary Home Sleep Testing Service. By signing below you are granting us permission to share your medical information with them and vise versa. Practice Type Provider Name City Phone Primary Care Provider Sleep Specialist Cardiologist Neurologist Pulmonologist: ENT (Ear, Nose, Throat) DDS (Dentist) Rheumatologist Gastroenterologist DME (Med. Equip. Supplier) Yourself Other Print Patient Name: Date: Sign Patient Name: 8128 E. Florentine Rd., Prescott Valley AZ ~ Tel.: (888) ~ Fax: (877) sms.patientservices@gmail.com ~

4 In Home Sleep Testing ~ We Come To You! Welcome and Thank You! Welcome and Thank you for choosing 1 Stop CPAP Shop, LLC for your In Home Sleep Testing! If at any time you have a question or concern please call (888) ext. 1, 24 hours a day / 7 days a week to speak to a technician. If necessary, please leave a message, include your phone number and a technician will call you right back. Also, if you have received this kit in the mail, please call Patient Service at (888) ext. 1 and let us know you have received it, so we can anticipate the return date. It is our privilege to provide you with the most advanced HST (Home Sleep Test) on the market today, to aid in your diagnosis and treatment of OSA (Obstructive Sleep Apnea). Home Sleep Test Kit and Instructions: HST Device - Alice NightOne Device to be used when you Sleep and Nap. HST Sleep Questionnaire - Completed and Returned with kit. Health Care Providers list you wish to receive your test results - Complete and Return with kit. User and Quick Start Guides Instructions for patient review Return With Kit. Instructional Video 3 Minute Patient Instruction Video at: Plastic Storage Bag Place Device in this bag when testing is complete. HST Device AA Batteries. Change between each use, Return with kit. Financial Responsibility Form, Insurance Gap Notice, and Tentative Return Date Agreement. Tentative Return/Pick up Date: and Time: Patient Instruction Acknowledgement Form Sign and Return with kit. If Mailing: Prepaid Self Addressed Stamped Return Package. Our Toll Free 24/7 Patient Service Number: ext. 1 Once you have received this HST kit, take a minute to measure your neck and complete the questionnaire. Watch the Instructional Video on our website and follow the easy direction for you In home Sleep Test. If you have any questions please call our Toll Free Patient Service Number: ext. 1. If it is after regular business hours, please leave a message with your phone number and a Home Sleep Test Technician will call you right back. After each 7 hour use, the device will automatically shut off. When testing is complete, repackage everything into the kit and return to SMS. Your test results will be available in about 10 business days. We will be happy to assist you and your Heath Care Providers with any needed treatment or therapy. Thank you again and we look forward to your test results. Sleep well! 8128 E. Florentine Rd., Prescott Valley AZ ~ Tel.: (888) ~ Fax: (877) sms.patientservices@gmail.com ~

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6 In Home Sleep Testing ~ We Come To You! Healthcare Provider List ~ Return With Device Hello and Thank you again for choosing 1 Stop CPAP Shop, LLC for your In Home Sleep Testing! In effort to provide the quickest results of your HST (Home Sleep Test) to your pertinent Health Care Provides (HCP); please provide us the Correct Name, City and Phone Number of each of your HCP listed below. This will allow all your HCP to be aware of your testing, diagnosis and any treatment plan. This will also allow 1 Stop CPAP Shop, LLC an opportunity to reach out to the providers whom may not otherwise know of our revolutionary Home Sleep Testing Service. By signing below you are granting us permission to share your medical information with them and vise versa. Practice Type Provider Name City Phone Primary Care Provider Sleep Specialist Cardiologist Neurologist Pulmonologist: ENT (Ear, Nose, Throat) DDS (Dentist) Rheumatologist Gastroenterologist DME (Med. Equip. Supplier) Yourself Other Print Patient Name: Date: Sign Patient Name: 8128 E. Florentine Rd., Prescott Valley AZ ~ Tel.: (888) ~ Fax: (877) sms.patientservices@gmail.com ~

7 In-Home Sleep Testing We Come To You! A Blue Cross Blue Shield Preferred Provider Home Of The In-Home Sleep Testing * Return With Device * 1 Stop CPAP Shop is always striving to improve our patient s health by staying current in both our techniques and diagnostic equipment. Recently we purchased a new technology that will allow you, the patient, to have your sleep studied in the comfort of your own home. Many of our patients were uncomfortable with the cost and process of outpatient sleep laboratories and we are excited to bring this new, easy to use and economical solution to our patients. *** While the monitoring device is in my possession, I agree to exercise care in its use and handling, and return it within the promised time frame in working condition. I understand that delays in its return causes problems for other patients who need this service device for testing. FINANCIAL RESPONSIBILTY AGREEMENT I understand that if the device is lost, stolen or damaged while in my possession or in transit, I am responsible to pay the insurance deductable for the replacement of this device. The deductable for the Home Sleep Test (HST) Device Kit and Auto PAP device is $ each and Pulse Oximeter is $ I am checking this device out on and I agree to return it on before 11am, at the conclusion of my testing so that other patients may have the same opportunity to be tested as I did. If I do not return it by the date above I agree to pay a $ per day late fee until the equipment is returned. I also agree that if I do not use the device while in my possession, I will pay a $50.00 non usage fee. Patient Print Name: Patient Signature: Date: ARES or Alice NightOne HST Device Serial #: (last 4 digits) Auto CPAP or Auto BiPAP Device Serial #: (last 4 digits) Pulse Oximeter Device Serial #: DT (last 4 digits) 8128 E. Florentine Rd. Suite A, Prescott Valley AZ ~ Tel: (888) ~ Fax: (877) sms.patientservices@gmail.com ~ Website:

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