TEMP TEST FORM Patient Registration Online (ID #4898)

Patient Details

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Please only include addresses where you are certain a package addressed to you will be received.
Would never dozeSlight chance of dozingModerate chance of dozingHigh chance of dozing
Sitting and reading
Watching TV
Sitting, inactive in a public place (e.g. a theater or a meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in the traffic

Health Insurance Details

The answer to this question is "No" if you are enrolled in a Managed Medicare program through a commercial insurance company.
Optional - only use if necessary to send additional information not provided elsewhere on this form. Please upload only one file for this option.

Patient Payment Details

We've worked diligently to provide our patients the most cost effective service possible. While we accept the majority of health insurance plans, there is typically a small out of pocket cost for a patient.
Your credit card information is encryped and stored securely to protect you from fraudulent use on a PCI compliant server. Internal Snap employees do not have access to, or visibility of, your credit card information. Any charges will show as "SNAP DIAGNOSTICS" on your credit card statement.

Important Details about Your Home Sleep Test

Please call Snap at 800-762-7786 if you are unable to complete the sleep test within ten days of receiving the test kit. Alternatively, you are agreeing to the following. If I do not return the Snap recorder to approved location within ten (10) days, by my signature below I authorize SNAP Diagnostics to charge the credit card provided above a fee of $500 to cover the expense of the recorder. If recorder is returned to SNAP the failure to return charge will be credited to my credit card. I also understand on rare occasions an insurance provider elects to issue the payment directly to a patient. I agree that I will forward to Snap Diagnostics the amount of any payment sent to me by my health insurance plan for the Snap Home Sleep Test within 10 days of receipt of that payment. If I fail to send the payment to Snap, within ten days of Snap notifying me of this rare event, I agree that Snap can charge my credit card on file for the amount I was reimbursed by the insurance provider for the Snap Home Sleep Test.
Patient Assignment of Benefits and Release Authorization. In considering the amount of medical expenses to be incurred, I, the undersigned, have insurance and/or employee health care benefits coverage with the above captioned, and hereby assign and convey directly to SNAP Diagnostics, LLC (SNAP) all medical benefits and/or insurance reimbursement, if any, otherwise payable to me for services rendered by SNAP. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize SNAP to release all medical information necessary to process this claim. I hereby authorize any plan administrator or fiduciary, insurer and my attorney to release to SNAP any and all plan documents, insurance policy and/or settlement information upon written request from SNAP in order to claim such medical benefits, reimbursement or any applicable remedies. I authorize the use of this signature on all my insurance and/or employee health benefits claim submissions. I hereby convey to SNAP to the full extent permissible under the law and under the any applicable insurance policies and/or employee health care plan any claim, chose in action, or other right I may have to such insurance and/or employee health care benefits coverage under any applicable insurance policies and/or employee health care plan with respect to medical expenses incurred as a result of the medical services I received from SNAP and to the extent permissible under the law to claim such medical benefits, insurance reimbursement and any applicable remedies. Further, in response to any reasonable request for cooperation, I agree to cooperate with SNAP in any attempts to pursue such claim, chose in action or right against my insurers and/or employee health care plan, including, if necessary, bring suit with such doctor and clinic against such insurers and/or employee health care plan in my name but at such doctor and clinic's expenses. Unless revoked, this assignment is valid for all administrative and judicial reviews under PPACA, ERISA, Medicare and applicable federal or state laws. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I have read and fully understand this agreement. I acknowledge SNAP diagnostics is releasing a Sleep Test Recorder to my possession and that the Recorder is property of SNAP Diagnostics. This recorder is to be returned in operating order by the date indicated by my prescribing practitioner. I have been trained on the use of the Snap equipment by video, person or written form. I have received a copy of the Notice of Privacy Practices.

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