Patient Consent & Authorization for Sleep Study at a Skilled Nursing Facility (SNF)

Facility Name: ________________________________  Unit/Room #: ____________
Patient Full Name: __________________________________  DOB: ____ / ____ / ______
MRN (if applicable): ___________________________  Phone (or Facility Ext.): __________
Primary Language: __________________  Interpreter Needed? ☐ No ☐ Yes (Language: ________)

☐ Type III Home Sleep Apnea Test (HSAT) at bedside
☐ Overnight Oximetry
☐ Other: ______________________________________________

Ordering Clinician: ____________________________________ NPI: _______________
Interpreting Physician (Board-Certified in Sleep Medicine): __________________________

This test evaluates sleep-related breathing disorders (e.g., obstructive sleep apnea, central apnea, nocturnal hypoxemia) and may guide treatment such as CPAP/BiPAP, oxygen titration, or other therapies.

• A Respiratory Therapist (RT) or trained staff will set up a portable recorder at your bedside (sensors on your finger, chest/abdomen belts, nasal cannula, and/or other non-invasive sensors).
   
• You will sleep in your SNF bed as usual. Staff will remove the equipment in the morning (unless otherwise ordered).
   
• Data are uploaded to a secure system and reviewed by a board-certified sleep physician. Results are sent to your care team.
   

Potential benefits: Identifying and treating sleep-related breathing issues to improve sleep quality, daytime alertness, cardiovascular and respiratory health, and reduce risk of rehospitalization.
Potential risks/discomforts (rare and usually mild): Skin irritation from adhesives, temporary redness or pressure marks, nasal dryness from cannula, minor sleep disruption, trip hazard from tubing/wires if you get out of bed.
Safety: Please call your nurse before getting out of bed. If you feel chest pain, severe shortness of breath, or other urgent symptoms, notify staff immediately. This test is not emergency care.

• Alternatives: In-lab polysomnography at a sleep center; no testing; or clinical treatment without testing (as determined by your clinician).
   
• Limitations: HSAT does not evaluate all sleep disorders (e.g., movement disorders, parasomnias) and can miss mild disease. A non-diagnostic or negative HSAT may lead to a recommendation for an in-lab study.
   

• Follow staff instructions during setup and removal.
   
• Avoid pulling on wires or removing sensors unless advised.
   
• Inform staff if you have skin sensitivity, implanted devices, or are on isolation precautions.
   
• Do not attempt to walk unassisted with sensors attached.
   

All equipment remains property of Sleep Lease Corporation. If any device is lost or damaged due to misuse, I understand the facility may bill according to policy and I may be financially responsible up to $________.
Device ID/Serial #: ______________________  Setup Date/Time: //______ at ______
Removal Date/Time: //______ at ______

• My sleep data and related health information will be collected, stored, and transmitted using HIPAA-compliant systems.
   
• I authorize Sleep Lease Corporation to use and disclose my information for treatment, payment, and healthcare operations, including sharing results with my SNF team, ordering clinician, interpreting physician, and payers.
   
• I acknowledge I have received or have access to the facility’s Notice of Privacy Practices.
   
• Records are retained consistent with applicable laws and facility policy.
   

• Results will be interpreted by a board-certified sleep physician and sent to the ordering clinician/SNF.
   
• I understand a telehealth or in-person follow-up may be recommended to review results and discuss treatment (e.g., CPAP/BiPAP).
   
• Abnormal results may prompt additional testing or specialist referral.
   

My participation is voluntary. I may refuse or stop the test at any time without affecting my right to present or future care or benefits to which I am otherwise entitled. I understand stopping early may limit interpretation.

• If I lack capacity, the below Legally Authorized Representative (LAR) affirms authority to consent on my behalf.
   
• Interpreter attestation (if used): I provided accurate interpretation in the patient’s preferred language and confirm the patient/LAR demonstrated understanding.
   

I have read (or had read to me) and understand this form. I had the chance to ask questions, and they were answered to my satisfaction. I consent to the sleep study described above and authorize the described uses/disclosures of my health information.

Patient Name (print): __________________________________  Signature: ______________________________
Date: ____ / ____ / ______  Time: ________  ☐ Patient has capacity

Legally Authorized Representative (if applicable):
Name/Relationship: ________________________________________  Signature: ____________________________
Authority: ☐ MPOA ☐ Guardian ☐ Next of Kin ☐ Other: ___________  Date/Time: _____________________

Interpreter (if applicable): Name/ID: __________________________  Language: __________________
Signature: _____________________________________________  Date/Time: _____________________

Witness (SNF staff/RT): Name/Title: ___________________________  Signature: __________________
Date/Time: _________________________

Sleep Lease Representative/RT: ___________________________  Signature: __________________  Date/Time: __________

Clinical Notes (optional): ____________________________________________________________________________

Contact: Sleep Lease Corporation • Phone: () - • Fax (secure): () -
Address: __________________________________________ • Email (secure): __________________________

Provider Use Only: ICD-10: ________  Indication: __________________________________  Order date: //______