Home Sleep Apnea Test Notices.

Direct Sleep Care, LLC (“DSC”) is permitting me the use of their Home Sleep Apnea Testing device for the sole purpose of a diagnostics sleep test for suspected sleep disordered breathing. I understand the testing device is to be utilized solely for this purpose and will only utilize the device as per the instructions of DSC and the instructional online material provided. I acknowledge and accept full responsibility for the testing device.

I acknowledge and accept full responsibility for the testing device once it has been delivered. I acknowledge that the device must be returned by or before the designated date set by DSC. With the exception of a carrier delay, if the device is not returned on the designated date, I understand that I will be charged a late fee of twenty-five dollars ($25.00) per day up to a maximum of five (5) days. I acknowledge that should the device not be returned after this period, the device will be considered lost and I will be financially responsible for the full replacement cost of the device.

Additionally, I acknowledge and accept that in the event I fail to return the equipment in the same working condition as it was when delivered to me, I will be liable for all damages, including full replacement if indicated necessary. I acknowledge and understand the repair and/or replacement cost may reach a total not exceeding $1,000. In the event the device is returned damaged, broken or is unreturned, I accept the full charge of $1,000 to the credit card on-file as reflected on this agreement & consent. Should a device which was previously considered lost and the replacement fee charged be returned, a refund of the replacement fee will be issued within ten (10) business days, minus a twenty-five dollar ($25.00) late fee charge for each day since the device was considered lost.

While shipping a device, I agree to only use the carrier assigned by DSC for the shipment and delivery of the device. I acknowledge that an error or delay in the return of the device by a carrier other than that assigned by OSM will be considered late and/or lost and I will be fully responsible for the associated costs outlined in this agreement.

Release of Information

I hereby request and authorize DSC to provide results and related materials pertaining to my Home Sleep Apnea Test.

Financial Responsibility

I understand and agree that l am responsible for the payment of any and all sums that may become due for the services provided. These sums include, but are not limited to, the all-inclusive Self Pay Rate for the Home Sleep Apnea Test, any applicable late fees, and any applicable repair/replacement fees. I understand and agree that should I have the Home Sleep Apnea Test device shipped to me and I knowingly or unknowingly fail to complete the test and/or I return the device late as defined in these Terms, that I may not be allowed a retest and/or refund. Any applicable fees will be non-refundable and non-transferrable regardless if I complete testing in-part or in-full.

Patient Notices and Privacy Policy

I authorize DSC to contact me now and in the future by all methods of which I or my referring provider have provided including but not limited to telephone, text messaging, and email. I understand that I have access to DSC's Patient Notices and Privacy Policy at www.directsleepcare.org.

Complaint Reporting

I acknowledge that I have been informed of the procedure to report a grievance should I become dissatisfied with any portion of my care experience. I understand that I may lodge a complaint without concern for reprisal, discrimination, or unreasonable interruption of service. To place a grievance, please email hello@directsleepcare.org.