Arlington Dental Associates Ira Stier DDS PC 876 Dutchess Tpk 2 Lafayette Ct. Poughkeepsie, NY Fishkill, NY

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1 Home Sleep Test Liability Form Study Equipment I, accept responsibility for the sleep monitoring device while it is in rny possession. I understand that if I fail to return the device or I return it damaged, I am responsible for the full replacement cost of $6, Furthermore, I have been made aware of the due date and I understand that if I fail to return the equipment on or before the due date noted I may be responsible for the cost of one night's study for each day I am late. Witness Signature:

2 Fee for Service Payment Policy Agreement The following is an outline of our offices payment policies and procedures regarding treatment for obstructive sleep apnea and bruxism treatment. By signing this document you acknowledge that you have read and understand the stated policies and agree to comply with the outlined payment terms. Insurance Claims Your insurance policy represents a contract between you and your insurance company. In most cases, we are NOT a party of this contract. Our office will prepare and submit the claim to your medical insurance carrier on your behalf. In order to help expedite the process, we ask that you provide us with your medical insurance card, benefit booklet and documentation that relates to sleep breathing disorders. It is your insurance company that makes the final determination of your eligibility and benefits. If your insurance company is not contracted with us, you agree to pay our office any portion of the charges not covered by insurance, including but not limited to those charges above the usual and customary allowance. If we are out of network for your insurance company or your insurance company pays you directly, you are responsible for payment and agree to forward the payment to us immediately.

3 Informed Consent for Oral Appliance Therapy for Snoring/Obstructive Sleep Apnea During sleep, the muscles and tissues of the upper airway can collapse and narrow or totally block the airway. Snoring occurs when the airway partially closes causing the tissues to reverberate when air passes through. Snoring is generally considered a mild condition and will generally result in limited daytime symptoms. Disruption to the sleep of the snorer's bed partner is the most common and irritating side effect. Obstructive sleep apnea (OSA) occurs when the airway is partially or fully blocked during sleep. OSA is a much more severe, life threatening condition in which the sufferer stops breathing repeatedly throughout the night. As a result of these frequent breathing stoppages, oxygen saturation levels in the bloodstream often drop to dangerous levels. Sleep patterns are disrupted because the body must fight to breath and frequently arouse the sufferer from sleep. The most common symptoms of obstructive sleep apnea are excessive daytime drowsiness from the lack, and poor quality, of sleep and snoring. Other symptoms and conditions that may become worse in patients with obstructive sleep apnea include frequent headaches, migraines, gastroesophageal reflux disease (GERD), high blood pressure, impotency, diabetes, depression, dementia, weight gain, hormonal imbalances, grinding, clenching, bruxism, broken teeth/dental work/dental implants, orthodontic problems, temporomandibular joint disorders, and orofacial pain disorders. When left untreated, OSA can be life threatening. Sleep Apnea dramatically increases the risk of heart attacks and strokes, especially during sleep. Because of the severity of the disorder, all patients are diagnosed with either a home sleep study test or overnight sleep study (polysomnography). Treatments for OSA include but are not limited continuous positive air pressure (CPAP), surgical procedures, oral appliances, and other modalities. In 2006, the American Academy of Sleep Medicine recommended that oral appliances be used as a first line treatment for mild to moderate OSA and severe OSA cases which are CPAP intolerant. FDA approved oral appliances used to treat OSA work by moving the jaw forward and opening the airway. Oral appliances may not reduce snoring or sleep apnea in all cases. Treatment with oral appliances may need to be discontinued if side effects such as sore jaw joints/muscles or excessive tooth movement occur. Other side effects may include excessive nocturnal salivation. There is no way to predict or guarantee that an oral appliance will be successful.

4 I have elected to wear an oral appliance while sleeping in an attempt to curtail snoring and/or Obstructive Sleep Apnea. The purpose of the oral appliance is to maintain an open airway passage which permits normal quiet breathing during sleep. I have been told that while this appliance can work well for many patients, due to physiological and anatomical variations and individual tolerance of the appliance, there can be no guarantee that it will be totally successful in my case. In addition to the above, I understand and am aware of the following conditions which may occur. Although the oral appliance is not intended to move my jaws or teeth, if I or my dentist notices these occurrences, I will contact the office immediately. If I have any dental, jaw or muscle discomfort, other than mild discomfort for the first few hours or so in the morning, I will inform the office. Since the oral appliance is designed to be highly retentive during sleep, existing dental restorations including crowns and/or bridges may occasionally loosen or fail. If this occurs, I agree to have the necessary dental work attended to as soon as possible. I have received, read and understand the conditions and information provided to me by my dentist and/or physician, which I was given during our consultation. I have had the opportunity to discuss the foregoing conditions and the information concerning the oral appliance. I also understand that there may be other unknown hazards and problems not described in this letter. Furthermore, I give my permission for my diagnostic and treatment records to be used for purposes of research, education or publication in professional journals. I also accept financial responsibility for this treatment. With all of the foregoing in mind, I authorize treatment and I have received a copy of this disclosure. The patient must read and understand the above paragraphs before an oral appliance can be delivered. By signing this document the patient accepts any and all risks involving the use of an oral appliance to treat OSA. Witness Signature:

5 CPAP INTOLERANCE FORM PATIENT NAME: I find CPAP intolerable to use on a regular basis due to the following reasons: I am unable to sleep with CPAP equipment in place. The noise from the device disturbs my sleep or my bed partner s sleep. I cannot find a comfortable mask. The mask leaks. I develop sinus / throat / ear / lung infections. I am allergic to materials in the mask and head straps. Claustrophobia I unconsciously remove the CPA apparatus at night. The pressure of the mask and straps cause tissue breakdown. My job and/or lifestyle prevent this form of therapy (e.g. Active Army / National Guard Duty) Prior throat surgery made CPAP intolerable. Refused to attempt CPAP usage. CPAP was ineffective in controlling my symptoms OTHER: Because of my inability to tolerate CPAP and my need to control the signs and symptoms of OSA, I wish to use an alternative method of treatment and would like to use oral appliance therapy. SIGNATURE: DATE:

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