*Home Sleep Apnea Test rental can be delivered to the patient's home for a $75 delivery fee.
*$xxx deposit for the Home Sleep Apnea Test rental. The $xxx deposit will be refunded once Home Sleep Apnea Test rental is returned. Depending on the patient's bank, the refunded amount could take up to 10 business days.
*Credit card on file will be charged for $xxx if the Home Sleep Apnea Test is not returned for any reason.
*Patient authorizes Alpha Sleep Center to charge credit card on file $xxx if health insurance does not cover the Home Sleep Apnea Test rental for any reason. If the patient's health insurance reimbursement is sent directly to the patient then the patient agrees to send Alpha Sleep Center the reimbursement within 5 business days of reimbursement receipt. If not received within 5 business days, the credit card on file will be charged for $xxx.
*Self-Pay Patient authorizes Home Sleep Apnea Test to charge $xxx for the Home Sleep Apnea Test rental.