- Home sleep testing requires physician prescription. We will prescribe, subject to your meeting the qualifications for a sleep study, and will then ship the equipment. State law requires us to disclose that you have the right to have prescriptions filled by any pharmacy of your choice. If you wish to have a prescription fulfilled by a pharmacy of your choice, please discontinue this process and contact us.
- By proceeding, you are afreeing to complete the medical review process, which includes a video interview with one of our medical specialists, either now or within seven business days. Failure to do so will void your order, in which case we will credit your credit card acoount less a 10% administrative processing fee.
Informed Consent for Sleep Telemedicine Consult
Introduction: Aviisha Medical Corporation uses telemedicine to provide sleep diagnostic studies to patients. Telemedicine involves use of electronic communications that enable health care providers and patients at different locations to share individual patient medical information for the purpose of patient care. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following: (1) patient medical records; (2) live two-way audio and video; and (3) Output data from medical devices and sound and video files.
Expected Benefits: The anticipated benefits include: (1) providing you access to medical care while enabling you to remain at a more convenient remote site and receive medical care from a distant location via the telemedicine network; (2)more efficient medical evaluation and management; and (3) obtaining the expertise of our distant sleep specialists.
Possible Risks: As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:
- In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s);
- Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
- In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
- In rare cases, a lack of access to complete medical records may result in adverse results or other judgment errors
By signing this below, I understand the following:
- I understand that I, or my legal representative, have the right to withhold or withdraw consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which the patient or the patient's legal representative would otherwise be entitled.
- I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent.
- I understand that I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee.
- I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. My physician has explained the alternatives to my satisfaction.
- I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
- I understand that it is my duty to inform my physician of electronic interactions regarding my care that I may have with other healthcare providers.
- I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
Authorization
1.1 The person signing Aviisha Equipment Lease Agreement (the Agreement) represents and warrants that he/she has been properly authorized and empowered to enter into the Agreement on behalf of such entity.
Delivery of Equipment
2.1 Aviisha will deliver the Equipment at its own risk to the Customer at the address designated by the Customer.
2.2 Aviisha will use reasonable efforts to deliver the Equipment by the requested Delivery Time but it shall not incur any liability to the Customer in the event of any delay caused by force majeure or other circumstances beyond its control.
2.3 The Customer will accept the Equipment when delivered on or before the Delivery Time and if for any reason the Customer fails to accept the Equipment when delivered on or before such date the Customer shall nevertheless be liable for the stated Rental Charge in full.
2.4 Lessor shall have the right, without notice, to substitute any rental equipment to that of equal or higher technical specifications at no additional charge to the Customer.
Charges
3.1 The Customer will pay the Rental Charge from the Arrival Time until the end of the Rental Period or the date all of the Equipment specified in the Rental Agreement is returned to and accepted by Aviisha. A $75 late fee shall be applied per day to any equipment not returned within 48 hours of receipt.
3.2 Aviisha has the right to request a security deposit of up to the retail list price of the Equipment. Aviisha requires a valid credit card number to be kept on file as a form of deposit. No charges will be applied to a credit card without making an effort to notify the Customer.
3.3 The Customer is responsible for rental charges and any applicable taxes during the entire period the Equipment is rented whether or not the Customer personally uses the Equipment to undergo a home sleep study.
3.4 Aviisha is entitled to bill the Customer, on a delayed basis, at any time after the Equipment has been returned for any and all charges for which the Customer shall be responsible pursuant hereto, whether or not Aviisha is aware of such charges at the time of the return of the Equipment. All charges and other amounts billed pursuant to this Agreement are payable by the Customer at the end of Rental Period as set forth in Section 3.5, or if not computed at the end of Rental Period, then upon demand given by Aviisha to the Customer.
3.5 The Rental Charge and any other amounts due to Aviisha under this Agreement are payable at the end of the Rental Period and Aviisha shall be entitled to charge late fees on any overdue amounts. In no event will any late payment charges exceed the highest lawful rate.
3.6 In the event of any loss, damage, theft or disappearance of the Equipment while on rental, regardless of circumstances, the Customer shall pay to Aviisha on demand, an amount equivalent to the value of the Equipment as identified in the Rental Agreement, less any deposit retained by Aviisha.
3.7 The Customer authorizes Aviisha to ask credit reporting agencies or trade references to furnish employment and credit information, and the Customer consents to Aviisha’s disclosure of credit information to credit reporting agencies.
3.8 The Equipment Rental charge includes overnight shipping or delivery charges each way. The method of such shipping, delivery or return, is solely at the discretion of Aviisha. If Customer ships or returns Equipment Rental by any other means without the prior consent, Customer shall be responsible for any charges incurred.
3.9 In the event the included pre-paid return label is lost, the Customer may request a replacement to be sent. However if that causes a delay in the return of equipment due, Customer will be charged for the extra days. To avoid extra charges, Customer should return equipment timely at their own expense.
Use of Equipment
4.1 Upon delivery to the Customer Aviisha will provide instructions on the use of the Equipment.
4.2 The Customer will use the Equipment in a careful and proper manner and in accordance with the instructions and in no other manner.
4.3 The Customer agrees that he/she will not:
4.3.1 effect any repairs or modifications to the Equipment;
4.3.2 remove or interfere with any certification markers affixed to the Equipment;
4.3.3 deface or add to the Equipment;
4.3.4 sublet or allow the use of the Equipment by any third party; or
4.3.5 attempt to dispose of the Equipment or to grant any interest in the Equipment to any third party.
Repairs
5.1 If the Equipment is not in working order when delivered or subsequently malfunctions then the Customer agrees to notify Aviisha immediately and to return the Equipment within 24 hours of receipt. If Customer fails to do return the Equipment in this manner, it is presumed the Equipment was delivered in good working condition and the Customer accepts equipment for use.
5.2 Aviisha will replace the malfunctioning Equipment, provided the Customer is not in breach of the Rental Agreement, by shipping replacement Equipment promptly upon receipt of the returned, malfunctioning Equipment.
5.3 If Aviisha finds that Equipment reported as faulty is in working order then the Customer will pay the cost of collection and delivery of the replacement Equipment.
Liability
6.1 Aviisha warrants that the Equipment will be in working order when it is delivered to the Customer.
6.2 AVIISHA MAKES NO OTHER WARRANTIES, GUARANTEES OR REPRESENTATIONS, EITHER EXPRESS OR IMPLIED, REGARDING ANY MATTER, INCLUDING WITHOUT LIMITATION, THE MERCHANTABILITY, ACCURACY, RELIABILITY, CONDITION OR FITNESS FOR A PARTICULAR PURPOSE OF THE EQUIPMENT OR THE CELLULAR PHONE SERVICES FURNISHED UNDER THIS AGREEMENT.
6.3 The Customer shall be solely responsible for and shall indemnify and hold harmless Aviisha against all claims, demands and liability arising as a result of lease, possession use, condition, operation or misuse of the Equipment or the Services provided hereunder whether in breach of Section 4 or otherwise arising howsoever.
6.4 AVIISHA WILL IN NO EVENT BE RESPONSIBLE NOR SHALL THE CUSTOMER MAKE ANY CLAIM AGAINST AVIISHA FOR ANY LIABILITY, CLAIM, LOSS, INJURY, DAMAGE OR EXPENSE OF ANY KIND (INCLUDING LOST PROFITS) WHETHER DIRECT, INDIRECT OR CONSEQUENTIAL CAUSED BY THE EQUIPMENT OR THE FAILURE OF THE EQUIPMENT TO OPERATE CORRECTLY OR AT ALL OR DELAY, FAULTINESS OR FAILURE OF THE SERVICES.
6.5 The Customer shall be liable to Aviisha for all expenses, including reasonable attorneys’ fees, collection fees and court costs incurred in connection with any collection, repossession or other action brought to enforce Aviisha’s rights under this Agreement.
Ownership
7.1 The Equipment will at all times remain the property of Aviisha. The Customer acquires no rights other than temporary use. During the Rental Period no service or part replacements are authorized without written approval from Aviisha. The Customer agrees that he/she has examined the Equipment and that the Equipment is in good working order at the time of receipt.
7.2 Customer shall immediately notify Aviisha of any theft, loss of or damage to the Equipment and shall, if applicable, provide evidence of theft by submitting a copy of a written police report to Aviisha within 24 hours of the theft. Customer shall bear the entire risk of loss or theft, damage or destruction for any cause whatsoever.
Termination
8.1 Unless otherwise agreed with Aviisha the Customer shall return the Equipment to Aviisha at the designated return address at the end of the Rental Period in good working order and in the same condition as when it was delivered to the Customer. The Customer shall return the Equipment by overnight courier and in accordance with shipping instructions provided by Aviisha at time of delivery of the Equipment. Should the Customer return the Equipment using means other than those specified in the instructions provided by Aviisha at the start of the rental, rental and other charges will continue, and the Customer will remain liable for any damage to the Equipment, while the Equipment is in transit. Packages returned with any components or pieces missing from the Equipment will continue to be charged full rental until all such missing components or pieces are returned or replacement value of the Equipment paid.
8.2 Should the Customer (a) obtain use of the Equipment by any misrepresentation or fraudulent mean, or (b) use the Equipment for any illegal or improper purpose, or in violation of applicable laws, or (d) otherwise commit a breach of these terms and conditions then Aviisha may, at its option and in addition to other remedies available hereunder at law or in equity, (i) terminate this Agreement; (ii) immediately terminate all services to the Customer, and (iii) take immediate possession of the Equipment without being obliged to repay any portion of the Rental Charges. Aviisha may also terminate this Agreement without any liability whatsoever to the Customer in the event that service is not available to Aviisha by a systems operator. No remedy of Aviisha shall be exclusive of any other remedy whether provided herein or available at law or in equity, but shall be cumulative with other remedies.
8.3 The Customer shall pay the manufacturer’s full retail price to Aviisha for any Equipment which is damaged or not returned at the end of the Rental Period.
8.4 If any execution or other writ or process shall be issued in any action or proceeding against Customer, whereby the said equipment may be seized or taken or if a proceeding in bankruptcy, receivership or insolvency shall be instituted by or against Customer or his property, or if Customer shall enter into any arrangement or composition with his creditors, or in the event that any judgment is obtained against the Customer, then and in any such event, Aviisha shall have the option to retake immediate possession of said equipment and, for such purpose, Aviisha, its agents or employees may enter upon any premises where said equipment is, and may remove the same there from with or without force, and with or without notice of intention to retake same, without being liable to any suit or action or other proceeding by Customer.
General
9.1 This Agreement shall be governed by the laws of the State of Calfironia. In addition, this Agreement is subject to applicable federal and state laws.
9.2 The headings in this Agreement are for convenience of reference only and shall not affect the meaning or construction of the terms and conditions contained herein.
9.3 No waiver by Aviisha of any breach of this Agreement shall be considered as a waiver of any subsequent breach of the same or any other provision hereof.
9.4 This Agreement cannot be assigned or transferred by the Customer, nor can this Agreement be modified (or any provision waived or modified) except by written instrument signed by Aviisha or its authorized agent. This Agreement constitutes the entire agreement between Aviisha and the Customer; there are no other representations, conditions, warranties, guarantees, or collateral I have read and agree to the rental agreement on the terms and conditions, and agree to have all unpaid charges put on my Visa, Master Card, American Express or Discover Card.