Our commitment is to provide personalized care and professional solutions for our patients.

Private Patient Agreement: I am aware that Valley Sleep and TMJ operates as a fee for service
practice. I am requesting to be seen as a patient and completely understand I will be
responsible for full fees on a private pay basis. I agree to pay for treatment services by the
providers at the fees schedule based on the private practice charges. All charges will be
discussed before any treatment is rendered.
HIPAA–Privacy Practices: I hereby authorize the release of all medical information necessary
to other providers rendering medical/dental care, as well as to labs that need my information
to make a diagnosis, treatment and/or fabricate an appliance necessary for my treatment.
Telemedicine Encounters: During any telemedicine encounter, details of your medical history,
examinations, x-rays and test will be discussed with Valley Sleep and TMJ, providers, clinical
assistants and treatment coordination staff through the use of interactive video, audio and
telecommunication technology. A physical examination or demonstration may take place.
Video, audio and or photo recording may be taken during this time for the evaluation and
assessment of your TMD and/or sleep condition(s) or symptoms associated.
Financial Responsibility: I understand that payment is immediately due when services are
rendered. If amounts due to the healthcare providers are not paid after reasonable notice and
healthcare provider’s efforts to collect, then the account will be considered delinquent – and
additional service charges may be added to the account balance to offset additional incurred
collection expenses.
Permission To Use Photographs & X-Rays: I consent to the taking of photographs and x-rays
before, during, and after treatment as they are a necessary part of the diagnostic procedure
and record keeping. I further give permission for the use of these photographs, x-rays, and
records to be used for the purpose of research, education, or publication in professional
journals. Our practice firmly believes that a good Doctor-Patient relationship is based on
understanding and communication.