ASD Slides (01/02/23): Slides

Congratulations on taking your first step to

a good night's sleep without a CPAP.

A sleep specialist will be with you shortly...

LOGIN

WHAT PROMPTED YOU TO CONTACT US?

HOW'S SLEEPING WITH YOUR CPAP?

Discreet & Quiet

Cleaning is Simple

Traveling is Light

Camping is a Breeze

NORMAL BREATHING

SLEEP APNEA BREATHING

HOW A CPAP WORKS

HOW A SLEEP APPLIANCE WORKS

5 EASY STEPS TO TREATING SLEEP APNEA AND REPLACING YOUR CPAP

ACCOMPLISHED IN THE COMFORT OF YOUR HOME

YOUR PERSONAL INFORMATION

First and Last Name?

YOUR PERSONAL INFORMATION

Name:

Is your name spelled correct?

YOUR PERSONAL INFORMATION

Address?

YOUR PERSONAL INFORMATION

Address:

,

Is your address correct?

YOUR PERSONAL INFORMATION

Cell Number?

YOUR PERSONAL INFORMATION

Cell Number:

Is your cell number correct?

YOUR PERSONAL INFORMATION

Phone Number?

YOUR PERSONAL INFORMATION

Phone Number:

Is your phone number correct?

YOUR PERSONAL INFORMATION

Email Address?

YOUR PERSONAL INFORMATION

Email:

Is your email correct?

YOUR PERSONAL INFORMATION

Gender?

YOUR PERSONAL INFORMATION

Date of Birth?

YOUR PERSONAL INFORMATION

Is your date of birth correct?

Date of Birth:

TIME ZONE

What time zone?

YOUR PERSONAL INFORMATION

Is your time zone correct?

Your Time Zone:

DO YOU HAVE DENTURES?

YOUR MEDICAL INFORMATION

Do you have Medicaid?

YOUR INSURANCE INFORMATION

Medicare?

Medicare Replacement?

Medical Insurance?

YOUR INSURANCE INFORMATION

Name of Insurance?

YOUR INSURANCE INFORMATION

Is the insurance name correct?

Name of Insurance:

YOUR INSURANCE INFORMATION

Claims Address?

YOUR INSURANCE INFORMATION

Is the claim address correct?

Claim Address:
, -

YOUR INSURANCE INFORMATION

Claim's Phone Number?

YOUR INSURANCE INFORMATION

Is the claim's phone number correct?

Claim's Phone Number:

YOUR INSURANCE INFORMATION

Claim's Fax Number?

YOUR INSURANCE INFORMATION

Is the claim's fax number correct?

Claim's Fax Number:

YOUR INSURANCE INFORMATION

Subscriber ID?

YOUR INSURANCE INFORMATION

Is the subscriber id correct?

Subscriber ID:

YOUR INSURANCE INFORMATION

Subscriber Name?

YOUR INSURANCE INFORMATION

Is the subscriber's name correct?

Subscriber Name:

YOUR INSURANCE INFORMATION

Subscriber Date of Birth?

YOUR INSURANCE INFORMATION

Is the subscriber's date of birth correct?

Subscriber Date of Birth:

YOUR INSURANCE INFORMATION

Relationship

to Subscriber?

YOUR INSURANCE INFORMATION

Is the relationship to subscriber correct?

Relationship to Subscriber:

YOUR INSURANCE INFORMATION

Group Name?

YOUR INSURANCE INFORMATION

Is the group name correct?

Name of Insurance:

YOUR SECONDARY INSURANCE INFORMATION

Do you have Secondary Insurance?

YOUR SECONDARY INSURANCE INFORMATION

Name of Secondary Insurance?

YOUR SECONDARY INSURANCE INFORMATION

Is the secondary insurance name correct?

Name of Insurance:

YOUR SECONDARY INSURANCE INFORMATION

Secondary Claim's Address?

YOUR SECONDARY INSURANCE INFORMATION

Is the address correct?

Insurance Address:
,

YOUR SECONDARY INSURANCE INFORMATION

Secondary Phone Number?

YOUR SECONDARY INSURANCE INFORMATION

Is the phone number correct?

Insurance Phone Number:

YOUR SECONDARY INSURANCE INFORMATION

Secondary Fax Number?

YOUR SECONDARY INSURANCE INFORMATION

Is the fax correct?

Insurance Fax Number:

YOUR SECONDARY INSURANCE INFORMATION

Secondary Subscriber ID?

YOUR SECONDARY INSURANCE INFORMATION

Is the subscriber ID correct?

Subscriber ID:

YOUR SECONDARY INSURANCE INFORMATION

Secondary Subscriber Name?

YOUR SECONDARY INSURANCE INFORMATION

Is the subscriber's name correct?

Subscriber Name:

YOUR SECONDARY INSURANCE INFORMATION

Secondary Subscriber's Date of Birth?

YOUR SECONDARY INSURANCE INFORMATION

Is the subscriber's date of birth correct?

Subscriber Date of Birth:

YOUR SECONDARY INSURANCE INFORMATION

Secondary Relationship to Subscriber?

YOUR SECONDARY INSURANCE INFORMATION

Is the relationship to subscriber correct?

Relationship to Subscriber:

YOUR SECONDARY INSURANCE INFORMATION

Secondary Group Name?

YOUR SECONDARY INSURANCE INFORMATION

Is the group name correct?

Group Name:

SECONDARY INFORMATION

Medicare Number?

SECONDARY INFORMATION

Is the Medicare number correct?

Medicare Number:

SECONDARY INFORMATION

Medicare State?

SECONDARY INFORMATION

Is the Medicare state correct?

Medicare State:

MEDICARE INFORMATION

Medicare Number?

MEDICARE INFORMATION

Is the Medicare number correct?

Medicare Number:

MEDICARE INFORMATION

Medicare State?

MEDICARE INFORMATION

Is the Medicare state correct?

Medicare State:

MEDICARE INFORMATION

Medicare Subscriber Name?

Subscriber Name:

RELEASE & AUTHORIZATION

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.

Callback

I'll call you back in 30 minutes at

INTEREST LEVEL

On a scale of 1-10 how likely are you to move forward?

APPOINTMENT DATE & TIME

Date:
Time:

APPOINTMENT DATE & TIME

Date:
Time:

YOUR INSURANCE INFORMATION

MEDICARE BENEFITS

Out of Pocket Expenses

Deductible

Coinsurance

Secondary Insurance

Out-of-Pocket Expense

___________________________

MEDICARE BENEFITS

Out of Pocket Expenses

Payment Plan

payments of

Payment due after fitting of sleep appliance

MEDICARE BENEFITS

Deductible Remaining After Receiving OA

MEDICARE BENEFITS

1 Payment

Payment Plan

payments of

Payment due after fitting of sleep appliance

MEDICARE BENEFITS

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?

MEDICARE BENEFITS

How much can you afford each month?

MEDICARE BENEFITS

Pay $0 until after you are fitted with a sleep appliance

Sleep Test

Charged $0 if you return sleep test.

Charged $200 if you do not return sleep test.

PAYMENT INFORMATION

Name on Credit Card?

PAYMENT INFORMATION

Billing Address?

PAYMENT INFORMATION

Address:

Is your billing information correct?

PAYMENT INFORMATION

Credit Card Number?

PAYMENT INFORMATION

Credit Card

Expiration Date?

PAYMENT INFORMATION

Credit Card

Security Code?

PAYMENT INFORMATION

Credit Card Number:

Expiration Date:

Security Number:

Is your credit card information correct?

INSURANCE BENEFITS

Out of Pocket Expenses

Deductible

Coinsurance

Secondary Insurance

Out-of-Pocket Expense

___________________________

INSURANCE BENEFITS

Out of Pocket Expenses

Payment Plan

payments of

Payment due after fitting of sleep appliance

INSURANCE BENEFITS

Deductible Remaining After Receiving OA

INSURANCE BENEFITS

1 Payment

Payment Plan

payments of

Payment due after fitting of sleep appliance

INSURANCE BENEFITS

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?

INSURANCE BENEFITS

We will waive your coinsurance.

$50 month payment.

INSURANCE BENEFITS

How much can you afford each month?

INSURANCE BENEFITS

Pay $0 until after you are fitted with a sleep appliance

Sleep Test

Charged $0 if you return sleep test.

Charged $200 if you do not return sleep test.

PAYMENT INFORMATION

Name on Credit Card?

PAYMENT INFORMATION

Billing Address?

PAYMENT INFORMATION

Address:

Is your billing information correct?

PAYMENT INFORMATION

Credit Card Number?

PAYMENT INFORMATION

Credit Card

Expiration Date?

PAYMENT INFORMATION

Credit Card

Security Code?

PAYMENT INFORMATION

Credit Card Number:

Expiration Date:

Security Number:

Is your credit card information correct?

INSURANCE BENEFITS

Out of Pocket Expenses

Deductible

Coinsurance

Secondary Insurance

Out-of-Pocket Expense

___________________________

INSURANCE BENEFITS

Out of Pocket Expenses

Payment Plan

payments of

Payment due after fitting of sleep appliance

INSURANCE BENEFITS

Deductible Remaining After Receiving OA

INSURANCE BENEFITS

1 Payment

Payment Plan

payments of

Payment due after fitting of sleep appliance

INSURANCE BENEFITS

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?

INSURANCE BENEFITS

We will waive your coinsurance.

$50 month payment.

INSURANCE BENEFITS

How much can you afford each month?

INSURANCE BENEFITS

Pay $0 until after you are fitted with a sleep appliance

Sleep Test

Charged $0 if you return sleep test.

Charged $200 if you do not return sleep test.

PAYMENT INFORMATION

Name on Credit Card?

PAYMENT INFORMATION

Billing Address?

PAYMENT INFORMATION

Address:

Is your billing information correct?

PAYMENT INFORMATION

Credit Card Number?

PAYMENT INFORMATION

Credit Card

Expiration Date?

PAYMENT INFORMATION

Credit Card

Security Code?

PAYMENT INFORMATION

Is your credit card information correct?

Credit Card Number:

Expiration Date:

Security Number:

INTEREST LEVEL

On a scale of 1-10 how likely are you to move forward?

INTEREST FREE PAYMENT PLAN

Interest: 0%

Payments: $50

Number of Payments: 18

INTEREST LEVEL

On a scale of 1-10 how likely are you to move forward?

PAYMENT INFORMATION

Name on Credit Card?

PAYMENT INFORMATION

Billing Address?

PAYMENT INFORMATION

Address:

Is your billing information correct?

PAYMENT INFORMATION

Credit Card Number?

PAYMENT INFORMATION

Credit Card

Expiration Date?

PAYMENT INFORMATION

Credit Card

Security Code?

PAYMENT INFORMATION

Credit Card Number:

Expiration Date:

Security Number:

Is your credit card information correct?

CONSENT

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.

SCHEDULE TELEHEALTH APPOINTMENT

What time zone?

TIME ZONE

Is your time zone correct?

Your Time Zone:

APPOINTMENT DATE & TIME

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:

I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment or risking the loss or withdrawal of any benefits to which I would otherwise be entitled.
The laws that protect the confidentiality of my medical information also apply to Telehealth. As such, I understand that the information disclosed by me during my Telehealth visit is generally confidential.
I understand that there are risks and consequences from Telehealth, including, but not limited to, the possibility that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.
I understand that I may benefit from telemedicine, but that results cannot be guaranteed or assured.
I understand that I have a right to access my medical information and copies of medical records in accordance with the law.
In addition, I understand that if the dentist believes I would be better served by face-to-face services, I will be referred to another healthcare provider who can provide such services in my area.
If you have an emergency, please Call 911. If it is not an emergency, you can call 800.555.1518.
You agree that your credit card will be charged $0 if the sleep test is returned. In the event that the sleep test is not returned, you consent that your credit card can be charged $200.
My medical insurance or Medicare will be billed for a sleep consultation, sleep test and diagnosis by a third party. My credit card maybe charged a maximum of $40 if my medical insurance or Medicare does not cover the cost of the sleep consultation and shipping, sleep test and diagnosis.