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I have received one of the following Home Sleep Apnea Testing devices from Jiva Health/REM Sleep Diagnostics.
I will carefully follow the instructions for the device received matching the picture below.

SleepImage Mobile App


You will need the Patient ID provided by Jiva Health

REMEMBER: Patient support can be reached at 800-818-4564

Failure to return the device after 48 hours serves as authorization to bill the responsible party the amount of $2000 for replacement of the device. I also agree to pay $25 per day beyond the return date and for all fees and costs associated with collecting this billable charge, including collection agency and attorney fees. These fees will be added to the purchase price.

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SCRF

Sleep Consultation Referral Form

To: REM Sleep Diagnostics Inc.
2601 Nut Tree Road, Suite C, Vacaville, CA 95687
Phone: 707-469-8400 Fax: 707-469-8469

Patient Assessment Questionnaire

REFERRAL FORM

Patient Information

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REFERRAL FORM

INSURANCE INFORMATION

THANK YOU IN ADVANCE FOR INCLUDING THE FOLLOWING INFORMATION:

History and Physical — describing the patient’s most recent history/physical and reason for referral. Current patient demographic information and a copy of insurance card.

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