Medigy LLC - Publicforms

Available Forms

AMA HST 1 Home Sleep Test Registration Form 1 HST 2 Home Sleep Test Delivery Ticket for filing insurance P3 Credit Card Authorization

HST 1 Home Sleep Test Registration Form 1

Equipment Agreement

Name *

Date of Birth *

Phone *

Mailing Address *

full mailing address

TERMS: The terms of this agreement shall begin on the date of setup/delivery/receipt of the rental products and will continue until I purchase it or return the equipment to the company.

LATE FEES; AGREEMENT/CHARGE FOR LOSS/DESTRUCTION Apnealink devices: I agree to pay any late fee for the equipment until the equipment is returned to the company. The first 7 days after the equipment is setup/received will NOT accrue rental charges. After the 14th day, the late fee for this equipment will be $50 per week until it is returned to the company. I hereby agree to borrow from Medigy LLC one (1) Wesper Home Sleep Testing Device consisting of 2 patches with charging pad and cable, 1 pulse oximeter with finger probe and charging cable and replacement adhesives. I understand that: 1. Delays in the return of the equipment are subject to a late initial fee of $50 and $30 per week after that per Wepser contract with Medigy LLC. I expressly authorize these fees to be charged to my credit card; 2. In the event the device is not returned, items are missing or damaged I am responsible for the full amount of this equipment ($299.00). I expressly authorize these fees to be charged to my credit card. The company reserves the right to require prepayment of the equipment. If the equipment is not returned or is lost/destroyed while in my possession or control, I agree to pay the company the full purchase price of $2500

TRAINING/ACCESSORIES/SUPPLIES: I agree to comply with all instructions via written or visual regarding the use of the equipment & accessories.

PERSONAL USE OF EQUPMENT AND/OR ACCESSORIES: I agree not to tamper with, adjust, or modify the equipment & accessories in any way other than outlined in the equipment manual, as prescribed by the ordering physician, or as recommended by the registered or licensed therapist or technician. I further agree to prevent any damage or destruction of the equipment. I will not permit any other person to use or possess the equipment without prior consent of the company. I further assume responsibility for all damage or abuse to the equipment & accessories except for normal wear & tear incurred as a result of prescribed usage of the rented equipment.

LIMITATION OF LIABILITY: EXCEPT IN THE EVENT OF THE WILLFUL OR GROSSLY NEGLIGENT CONDUCT OF COMPANY EMPLOYEES, PATIENT ACKNOWLEDGES & AGREES THAT IN NO EVENT SHALL COMPANY BE LIABLE FOR ANY CLAIMS OR DAMAGES ARISING OUT OF PATIENT?S USE OF THE EQUIPMENT RENTED HERE-UNDER.

MISCELLANEOUS MATTERS: This agreement shall be binding upon the benefit of the parties & their respective successors & permitted assigns. In any arbitration or litigation, including concerning this agreement, the prevailing party shall be entitled to recover all reasonable expenses of arbitration or litigation, including reasonable attorney fees at arbitration, at trial & on any appeal or petition for review. This agreement constitutes the entire agreement between the parties with respect to the rental of equipment by company to patient & supersedes any prior agreement or understanding.

I certify that I have read and understand this rental agreement & fully agree to its explanation & terms

Electronic Signature *

Date of Signature *

HST Screening Form

Name *

Date of Birth *

Gender *

Height *

Weight *

Typical Bedtime & Waketime *

Daytime Sleepiness *

Loud Snoring *

Epworth Sleepiness Scale

How tired are you, and how likely are you to doze off at inappropriate times? Read the following situations and use the scale to rate your sleepiness:0=Not Sleepy1=Slightly Sleepy2=Moderately Sleepy3=Highly Sleepy

Sitting and Reading *

Watching TV *

Sitting inactive in a public place *

As a passenger in a car for an hour w/o a break *

Lying down to rest in the afternoon *

Sitting and talking to someone *

Sitting quietly after lunch w/o alcohol *

In a car while stopped for a few minutes in traffic *

Please list any treatments, medical history, comments or medical issues you think pertain to your sleep or your breathing while sleeping

THANK YOU FOR COMPLETING THE FORMS. IF YOU HAVE ANY QUESTIONS PLEASE CONTACT US @ 817.379.6334

* Required field