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Reimbursement Acknowledgment 

Please be advised that you may receive a check from your insurance company for treatment of Obstructive Sleep Apnea. This check reflects the amount owed to our office for the equipment customized for you.

Please sign the back of the check and forward to us along with a copy of your driver’s license.

If the check is made out to the primary insured, please provide us a copy of their license.

You may also include a personal check in the amount owed.

Please feel free to contact our office at 828-649-7114 with any questions you may have.

 

I understand that any check/money recieved by me in the mail is not for me to keep


I understand that any check/money I receive is to be immediately paid to the office receipt


I understand that if I keep the check/money mailed to me by the insurance company that it is considered insurance fraud


 

 

 

First Patient Name

First Name*

Middle Name

Last Name*

Phone*
First Patient Date of Birth*
First Patient Signature*
Second Patient Name

First Name*

Middle Name

Last Name*
Second Patient Date of Birth*
Third Patient Name

First Name*

Middle Name

Last Name*
Third Patient Date of Birth*
Fourth Patient Name

First Name*

Middle Name

Last Name*
Fourth Patient Date of Birth*
Fifth Patient Name

First Name*

Middle Name

Last Name*
Fifth Patient Date of Birth*
Sixth Patient Name

First Name*

Middle Name

Last Name*
Sixth Patient Date of Birth*
Seventh Patient Name

First Name*

Middle Name

Last Name*
Seventh Patient Date of Birth*
Eighth Patient Name

First Name*

Middle Name

Last Name*
Eighth Patient Date of Birth*
Ninth Patient Name

First Name*

Middle Name

Last Name*
Ninth Patient Date of Birth*
Tenth Patient Name

First Name*

Middle Name

Last Name*
Tenth Patient Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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