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Consent Agreement:

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HIPAA Federal regulations require us to protect your privacy and as such, we will not release any information about you without your prior consent. By agreeing to this consent, you permit the release of any information from your health questionnaire to our board-certified sleep physicians as that information is required to authorize a home sleep test and for your follow-up telehealth visit. Your information will be secure and never released to any additional parties unless written notification is provided by you. You understand that you are financially responsible for all charges whether or not paid by insurance.

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Your order

Product	Subtotal
SimpleRx: Online CPAP Prescription Renewal Package × 1	$79.00
Subtotal	$79.00
Total	$79.00

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Please send your check to 8353 Mentor Ave, Ste 2, Mentor OH 44060.