Congratulations on taking your first step to
a good night's sleep without a CPAP.
A sleep specialist will be with you shortly...
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Discreet & Quiet
Cleaning is Simple
Traveling is Light
Camping is a Breeze
First and Last Name?
Name:
Is your name spelled correct?
Address?
Address:
,
Is your address correct?
Cell Number?
Cell Number:
Is your cell number correct?
Phone Number?
Phone Number:
Is your phone number correct?
Email Address?
Email:
Is your email correct?
Gender?
Date of Birth?
Is your date of birth correct?
Date of Birth:
What time zone?
Is your time zone correct?
Your Time Zone:
Do you have Medicaid?
Medicare?
Medicare Replacement?
Medical Insurance?
Name of Insurance?
Is the insurance name correct?
Name of Insurance:
Claims Address?
Is the claim address correct?
Claim Address:
, -
Claim's Phone Number?
Is the claim's phone number correct?
Claim's Phone Number:
Claim's Fax Number?
Is the claim's fax number correct?
Claim's Fax Number:
Subscriber ID?
Is the subscriber id correct?
Subscriber ID:
Subscriber Name?
Is the subscriber's name correct?
Subscriber Name:
Subscriber Date of Birth?
Is the subscriber's date of birth correct?
Subscriber Date of Birth:
Relationship
to Subscriber?
Is the relationship to subscriber correct?
Relationship to Subscriber:
Group Name?
Is the group name correct?
Name of Insurance:
Do you have Secondary Insurance?
Name of Secondary Insurance?
Is the secondary insurance name correct?
Name of Insurance:
Secondary Claim's Address?
Is the address correct?
Insurance Address:
,
Secondary Phone Number?
Is the phone number correct?
Insurance Phone Number:
Secondary Fax Number?
Is the fax correct?
Insurance Fax Number:
Secondary Subscriber ID?
Is the subscriber ID correct?
Subscriber ID:
Secondary Subscriber Name?
Is the subscriber's name correct?
Subscriber Name:
Secondary Subscriber's Date of Birth?
Is the subscriber's date of birth correct?
Subscriber Date of Birth:
Secondary Relationship to Subscriber?
Is the relationship to subscriber correct?
Relationship to Subscriber:
Secondary Group Name?
Is the group name correct?
Group Name:
Medicare Number?
Is the Medicare number correct?
Medicare Number:
Medicare State?
Is the Medicare state correct?
Medicare State:
Medicare Number?
Is the Medicare number correct?
Medicare Number:
Medicare State?
Is the Medicare state correct?
Medicare State:
Medicare Subscriber Name?
Subscriber Name:
I, , authorize the release of any medical or other information necessary to determine eligibility and if I decide to proceed with the sleep appliance, seek reimbursement for the sleep appliance. I am giving American Sleep Dentistry the authorization and their affiliates to use information that may be confidential, privileged, and protected by law.
After American Sleep Dentistry provides me with any out-of-pocket expense, if I decide to proceed with the sleep appliance, I authorize payments for the sleep appliance furnished to me by American Sleep Dentistry to be paid directly to American Sleep Dentistry. I authorize payments for the sleep test furnished to me by iSleep Physician Group PC to be paid directly to iSleep Physician Group PC. I agree that I am responsible for payment of the cost of services that my insurance company does not pay, as well as any copayment or deductible for which I am responsible.
I appoint American Sleep Dentistry and iSleep Physician Group PC to act as my representative in connection with my claim or asserted right under Title 18 of the Social Security Act (the Act) and related provisions of Title 11 of the Act. I authorize this individual to make any request; to present or to elicit evidence; to obtain appeals information; and to receive any notice in connection with my claim, appeal, grievance or request wholly in my stead. I understand that personal medical information related to my appeal may be disclosed to the representative indicated below.
I'll call you back in 30 minutes at
On a scale of 1-10 how likely are you to move forward?
Date:
Time:
Date:
Time:
Out of Pocket Expenses
Deductible
Coinsurance
Secondary Insurance
Out-of-Pocket Expense
___________________________
Out of Pocket Expenses
Payment Plan
payments of
Payment due after fitting of sleep appliance
Deductible Remaining After Receiving OA
1 Payment
Payment Plan
payments of
Payment due after fitting of sleep appliance
How many persons reside in your household?
How many people are in your family?
How much money did you report on your taxes last year?
How much can you afford each month?
Pay $0 until after you are fitted with a sleep appliance
Charged $0 if you return sleep test.
Charged $200 if you do not return sleep test.
Name on Credit Card?
Billing Address?
Address:
,
Is your billing information correct?
Credit Card Number?
Credit Card
Expiration Date?
Credit Card
Security Code?
Credit Card Number:
Expiration Date:
Security Number:
Is your credit card information correct?
Out of Pocket Expenses
Deductible
Coinsurance
Secondary Insurance
Out-of-Pocket Expense
___________________________
Out of Pocket Expenses
Payment Plan
payments of
Payment due after fitting of sleep appliance
Deductible Remaining After Receiving OA
1 Payment
Payment Plan
payments of
Payment due after fitting of sleep appliance
How many persons reside in your household?
How many people are in your family?
How much money did you report on your taxes last year?
We will waive your coinsurance.
$50 month payment.
How much can you afford each month?
Pay $0 until after you are fitted with a sleep appliance
Charged $0 if you return sleep test.
Charged $200 if you do not return sleep test.
Name on Credit Card?
Billing Address?
Address:
,
Is your billing information correct?
Credit Card Number?
Credit Card
Expiration Date?
Credit Card
Security Code?
Credit Card Number:
Expiration Date:
Security Number:
Is your credit card information correct?
Out of Pocket Expenses
Deductible
Coinsurance
Secondary Insurance
Out-of-Pocket Expense
___________________________
Out of Pocket Expenses
Payment Plan
payments of
Payment due after fitting of sleep appliance
Deductible Remaining After Receiving OA
1 Payment
Payment Plan
payments of
Payment due after fitting of sleep appliance
How many persons reside in your household?
How many people are in your family?
How much money did you report on your taxes last year?
We will waive your coinsurance.
$50 month payment.
How much can you afford each month?
Pay $0 until after you are fitted with a sleep appliance
Charged $0 if you return sleep test.
Charged $200 if you do not return sleep test.
Name on Credit Card?
Billing Address?
Address:
,
Is your billing information correct?
Credit Card Number?
Credit Card
Expiration Date?
Credit Card
Security Code?
Is your credit card information correct?
Credit Card Number:
Expiration Date:
Security Number:
On a scale of 1-10 how likely are you to move forward?
Interest: 0%
Payments: $50
Number of Payments: 18
On a scale of 1-10 how likely are you to move forward?
Name on Credit Card?
Billing Address?
Address:
,
Is your billing information correct?
Credit Card Number?
Credit Card
Expiration Date?
Credit Card
Security Code?
Credit Card Number:
Expiration Date:
Security Number:
Is your credit card information correct?
I, , authorize that payments for medical supplies furnished to me by American Sleep Dentistry, be paid directly to American Sleep Dentistry. I agree to 18 interest-free monthly payments of $50 each for a total of $900.
What time zone?
Is your time zone correct?
Your Time Zone:
Date:
Time:
I consent to engaging in Telehealth with ASD Sleep and iSleep Physician Group PC. I understand that “telemedicine or Telehealth” includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. I understand that Telehealth also involves the communication of my medical, both orally and visually, to health care practitioners.
I understand that I have the following rights with respect to Telehealth:
Cell Number?
Cell Number:
Is your cell number correct?
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