Patient Information

Patient Information
Patient Forms
Accepted Insurance
FAQs
Financial Policy
Privacy Practices

Nothing is more important to Gwinnett Sleep
than patient satisfaction. Your time is valuable.
Your quality of sleep is vital.

That’s why we provide online patient forms.
Save time during appointments by reviewing
documents in advance.

Patient Portal

Sign in to review patient forms, including a list of accepted insurance health plans, a patient survey, our financial policy and privacy policy, FAQs and more.

Patient Forms

Below you’ll find all the patient paperwork you need before your visit to Gwinnett Sleep. Please print and fill out this form when it is most convenient for you, and we will ensure your first visit is as efficient as possible.

Adobe Reader needed to view PDF files.

Sleep study paperwork here

Accepted Insurance

Overnight sleep testing is a procedure covered by most insurance plans, as well as Medicare. Gwinnett Sleep is happy to assist patients by verifying coverage and obtaining pre-certification or authorization the insurance.

Aetna (HMO/POS/PPO)
Blue Cross Blue Shield (HMO/POS/PPO)
Beechstreet (PPO)
Cigna (HMO/POS/PPO)
Coventry/Promina
Humana (HMO/POS/PPO)

Medicare
PHCS (POS /PPO)
Principal
Tricare
United Healthcare (HMO/POS/PPO)

Please be aware that we take many other insurance plans. Please give us a call if you do not see your insurance plan listed above.

FAQs

At Gwinnett Sleep, we want your experience to be as easy as possible. Here are answers to commonly-asked questions about our sleep disorder center.

Q. What types of sleep problems can be evaluated at a Sleep Disorders Center?

A. All sleep-related problems can be evaluated. Common sleep issues include insomnia (trouble falling asleep or staying asleep). Another common problem is daytime sleepiness, which may be a result of more serious sleep disorders, including sleep apnea and narcolepsy. Some of the more popular causes of insomnia are Restless Legs Syndrome (RLS), medication dependency and anxiety/ depression.

Q. What do Sleep Disorders Evaluation include?

Q. Will my insurance cover Sleep Evaluations at Gwinnett Sleep?

Q. What do Sleep Disorders Evaluation include?

Q. Can I take my usual medications?

Financial Policy

The Gwinnett Sleep team understands our patients have unique sleep disorders
and financial realities. We do our best to work with you, within your means, in
order to provide the best care possible.

We understand how helpful it can be to know in advance how payment
arrangements are handled. Outlined below are our basic financial policies.

Gwinnett Sleep requires a copy of your insurance card and co-payment at the
time of check-in — before your visit with the physician begins.

If Gwinnett Sleep participates in your insurance plan, we will file charges with
your insurance company on your behalf. If we do not participate in your
insurance plan, payment for services rendered will be collected at the time of
service.

***We are pleased to offer uninsured patients or patients that have insurance plans we do not participate in a variety of payment plan options. Please contact our insurance department for further details at (678) 942-5982.***

After we file your insurance, we will wait 60 days for payment from your insurance company. If payment has not been received in 60
days, we will transfer the account to patient responsibility. We ask that you follow-up with your insurance company to ensure claims
are processed timely. Please communicate findings so we may remain on sound financial footing.

Although we are reluctant to do so, we utilize a collection agency for accounts not paid within 90 days. Once an account has been
sent to the collection agency, it cannot be retrieved. Your insurance company will respond to your future inquiries swifter than ours.
We have discovered patients that maintain timely communication with their insurance companies ensure their claims are processed
appropriately and avoid the collection process. Prompt payment of any balances remaining after insurance has paid will keep your
account in good standing.

Charges for lab services performed outside of our office are billed separately and are not typically included with the physician’s bill.

Request for medical records are handled promptly. Sometimes, records must be retrieved from storage. Our charges for copying
medical records are based on the charges set forth by the Georgia Office of Planning and Budget pursuant to O.C.G.A 31-33-3. In
order to comply with HIPAA regulations, a signed, written request for medical records must be received, along with payment, before
records can be released.

Varying fees are charged for requested forms and letters.

Please let us know at least 24 hours prior to your scheduled appointment time if you will not be able to keep your appointment.
Appointments not cancelled in a timely manner will be assessed a “No Show” fee.

We accept Visa, MasterCard, American Express, and Discover, as well as cash and personal checks drawn on a local bank with a
pre-printed name, address, and phone number.

Checks returned for insufficient funds are assessed a $30 fee.

Checks that are returned by the bank as non-paid are assessed a $30 bad check fee. The amount of the non-paid check and $30
bad check fee are due within 10 days. We reserve the right to require payment of the non-paid check and the bad check fee by another method other than check (cash, credit/debit, money order). Failure to rectify this situation within 10 days will result in
the account being sent to our collection agency.

Privacy Practices

Our patient’s privacy is of the utmost importance to us. The Gwinnett Sleep team abides by strict privacy regulations in order to ensure all of our patients feel secure.

This notice describes how medical information about you may be used and
disclosed and how you can get access to this information. Our commitment to
your privacy: Your information is important and confidential. Our ethics and
policies require that your information be held in strict confidence.

Gwinnett Pulmonary Group

Notice of Privacy Practices

Effective April 14, 2003

Understanding your health record

Each time you visit Gwinnett Sleep, a record of your visit is created. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment and plan for your future care or treatment. This information, often referred to as your health or medical record, serves as a basis for planning your care and treatment; means of communication among health professionals who contribute to your care; legal documents that describe the care you receive; means by which you or a third-party payer can verify that services billed were provided; tools in educating health professionals; source of data for medical research; source of information for public health officials; charges to improve the health and state of the nation; source of data for our planning and marketing and tool by which we can assess and continually work to improve the care and outcomes we render.

Understanding what is in your record and how your health information is used helps you to:

Ensure its accuracy
Better understand who, what, when, where, and why others may access your health information
Make more informed decisions when authorizing disclosure to others.

Your health information rights

Although your health record is the physical property of Gwinnett Sleep/Gwinnett Pulmonary Group, the information belongs to you. You have the right to:

Obtain a paper copy of this notice of privacy policies upon request
Inspect and obtain a copy of your health record as provided by 45 CFR 164.524
(reasonable copies of fees in accordance with state laws)
Amend your health record as provided by 45 CFR 164.522(b)
Request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522(a)
(We are not required by law to agree to a requested restriction)

Our responsibilities Our practice is required to:

Maintain the privacy of your health information
Provide this notice of our legal duties and privacy practices with respect to information we collect and maintain about you
Abide by the terms of this notice
Notify you if we are unable to agree to a requested restriction
Accommodate reasonable requests about your health information

We reserve the right to change our practices and make new provisions effective for all protected health information we maintain. We will keep a posted copy of the most current notices in our facility containing the effective date in the top, right-hand corner. In addition, each time you visit our facility for treatment, you may obtain a copy of the current notice in effect, upon request. We will not use or disclose your health information in a manner other than described in the section regarding Examples Of Disclosures For Treatment, Payment, And Health Operations, without your written authorization — which you may revoke — as provided by 45 CFR 164.508(b)(5), except to the extent that action has already been taken.

Understanding your health record

If you have questions or would like additional information, you may contact our Practice Privacy Officer, Nicole Boyles, at (770) 995-0630. If you believe your privacy rights have been violated, you can file a complaint with Nicole Boyles or the Office for Civil Rights, U.S. Department of Health and Human Services (OCR). There will be no retaliation for filing a complaint.

U.S. Department of Health

& Human Services

Atlanta Federal Center, Suite 3B70
61 Forsyth Street, SW
Atlanta, GA 30303-8909

Examples of disclosures for treatment, payment, and health options

We will use your health information for treatment. We may provide medical information about you to health care providers, our Practice personnel, or third parties who are involved in the provision, management, or coordination of your care. For example, information obtained by a nurse, physician, or other member of your health care team will be documented in your record and utilized to determine the course of treatment that should work best for you. Your medical information will be shared among healthcare professionals involved in your care. We will also provide your other physician(s) or subsequent health care provider(s) (when applicable) copies of various reports that should assist them in treating you.

We will use your health information for payment. We may disclose your information so that we can collect or make payment for the Healthcare services you receive. For example, if you participate in a health insurance plan, we will disclose necessary information to that plan to obtain payment for your care.

We will use your health information for regular operations. We may disclose your health information for our routine operations. These uses are necessary for certain administrative, financial, legal, and quality improvement activities that are necessary to run our practice and support the core functions. For example: Members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of healthcare and services we provide reduce healthcare costs.

Appointment Reminders

We may disclose medical information to provide appointment reminders (e.g., contact you at the phone number, email address, etc. you provided our office and leave a messages as an appointment reminder).

Decedents

Consistent with applicable law, we may disclose health information to a coroner, medical examiner, or funeral director.

Workers Compensation

We may disclose health information to the extent authorized by and necessary to comply with laws relating to workers compensation or other similar programs established by law.

Public Health

As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Research

We may disclose information to researchers when their research has been approved and the researcher has obtained a required waiver from the Institutional Review Board/Privacy Board, who has reviewed the research proposal.

Organ Procurement Organizations

Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of donation and transplant.

As Required By Law

We may disclose health information as required by law. This may include reporting a crime, responding to a court order, grand jury subpoena, warrant, discovery request, or other legal process, or complying with health oversight activities, such as audits, investigations, and inspections, necessary to ensure compliance with government regulations and civil rights laws.

Specialized Government Functions

We may disclose health information for military and veterans affairs or national security and intelligence activities.

Business Associates

There are some services provided in our organization through contacts with business associates. Some examples are billing or transcription services we may use. Due to the nature of business associates’ services, they must receive your health information in order to perform the jobs we’ve asked them to do. To protect your health information, however, when these services are contracted, we require the business associate to appropriately safeguard your information.

Practice Marketing

We may contact you to provide information about treatment alternatives or other health-related benefits and services that may be of interest to you (for example, to notify you of any new tests or services we may be offering).

Food and Drug Administration (FDA)

We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.

Personal Representative

We may disclose information to your representative (person legally responsible for your care and authorized to act on your behalf in making decisions related to your healthcare).

To Avert A Serious Threat To Health/Safety

We may disclose your information when we believe in good faith that this is necessary to prevent a serious threat to your safety or that of another person. This may include cases of abuse, neglect, or domestic violence.

Communication With Family

Unless you object, health professionals, using their best judgment, may disclose to a family member or close personal friend health information relevant to that person’s involvement in your care. We may notify these individuals of your location and general condition.

Disaster Relief

Unless you object, we may disclose health information about you to an organization assisting in a disaster relief effort.

For all non-routine operations, we will obtain your written authorization before disclosing your personal information. In addition, we take great care to safeguard your information in every way that we can to minimize any incidental disclosures.