Patient Consents

I voluntarily consent to evaluation, diagnosis, and treatment by physicians and authorized clinical staff of ZYRA Sleep & Wellness, including examinations, diagnostic tests, and treatments considered medically appropriate.

I understand that no guarantees have been made regarding the outcome of my care.

I understand that I have the right to refuse any examination, diagnostic test, or treatment, and to be informed of the medical consequences of such refusal. Refusal will not affect my right to future care except as medically necessary.

I authorize care to be provided by physicians, nurse practitioners, physician assistants, nurses, technicians, trainees, and other healthcare personnel involved in my care under the direction of the treating provider.

I consent to the use of telehealth services when offered or recommended by my provider. I understand that:

• Telehealth may involve audio, video, or electronic communication technologies
• Telehealth services may have limitations compared with in-person visits
• Technical interruptions may occur
• Telehealth is not appropriate for medical emergencies — I will call 911 or go to my nearest emergency room if I am experiencing a medical emergency
• I may withdraw my consent for telehealth services at any time by contacting the clinic at (972) 942-9972 or through the contact page

ZYRA Sleep & Wellness uses an AI-assisted transcription tool to support clinical documentation. During my visit, the conversation may be transcribed by this technology to assist in generating accurate clinical notes.

• The AI transcription vendor operates under a Business Associate Agreement (BAA) in compliance with HIPAA
• Transcriptions are reviewed and finalized by the treating provider before being added to my medical record
• I may request manual documentation without the use of AI transcription by notifying the clinic prior to my visit

ZYRA Sleep & Wellness does not discriminate in the provision of services on the basis of race, color, national origin, sex, age, or disability. If you believe you have been subjected to discrimination, you may contact us at (972) 942-9972 or file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights at ocrportal.hhs.gov or by calling (800) 368-1019.

I authorize ZYRA Sleep & Wellness to use and disclose my protected health information as permitted by law for purposes of Treatment, Payment, and Healthcare Operations (TPO). This may include sharing information with:

• physicians and healthcare providers involved in my care
• other clinics or specialists involved in treatment or referrals
• laboratories, imaging centers, pharmacies, and durable medical equipment suppliers
• insurance companies and billing partners
• healthcare operations activities such as quality improvement, auditing, and compliance

I authorize ZYRA Sleep & Wellness to access and obtain my health information from other healthcare providers, health information exchanges, pharmacies, prescription history services, laboratories, imaging centers, and insurance systems when such information is available electronically. This may include:

• prior medical records
• medication and prescription history
• laboratory and imaging results
• treatment history from other healthcare providers

This information may be used by my healthcare providers to assist in diagnosis, treatment, and coordination of my care.

I authorize ZYRA Sleep & Wellness to communicate with me using the contact information I provide. Communications may occur through:

• phone calls or voicemail
• text messages (SMS)
• email
• patient portal messaging

These communications may include appointment reminders, test results, treatment instructions, billing information, and other healthcare-related communications. Standard messaging or data rates may apply. I understand that I may request limitations on communication methods by notifying the clinic.

I understand that I am financially responsible for all charges for services provided by ZYRA Sleep & Wellness that are not paid by my insurance.

I hereby authorize my insurance benefits to be paid directly to ZYRA Medical Group PLLC for services rendered. This assignment remains in effect until revoked in writing. I understand that I am responsible for any balance not covered by my insurer.

I agree to provide accurate and current insurance information at each visit. I understand that it is my responsibility to notify the clinic of any changes to my insurance coverage prior to receiving services.

I am required to disclose all insurance coverage, including any secondary, supplemental, or coordination-of-benefits plans. If a secondary plan would have covered a balance and was not disclosed, I accept full financial responsibility for that balance.

If claims are denied or cannot be processed because I failed to provide updated or complete insurance information in a timely manner, I understand that I am responsible for the full balance of those charges.

I understand that it is my responsibility to obtain any required prior authorizations from my insurance carrier before receiving services. The clinic will assist in submitting authorization requests, but I remain financially responsible if authorization is not obtained.

I understand that I am responsible for copayments, deductibles, coinsurance, and services not covered by my insurance. Copayments and self-pay balances are due at the time of service. Insurance balances are due within 30 days of statement date. Self-pay patients are responsible for payment according to clinic policies.

If I choose to provide a credit or debit card to be kept on file, I authorize the clinic to charge this card for balances related to services provided to me after my insurance has processed the claim or when payment is otherwise due.

Outstanding balances may need to be paid prior to future appointments. The clinic may reschedule non-urgent appointments if required payments are not made.

Accounts with balances that remain unpaid for over 90 days are referred to a collections agency in accordance with clinic policy.

A $35 fee will be assessed for any returned check or declined ACH payment. Repeat returned payments may require cash or card payment going forward.

Appointments that are missed or cancelled without at least 48 hours advance notice may be subject to a $50 fee. Please contact the clinic as soon as possible if you need to cancel or reschedule.

We are required by law to maintain the privacy of your protected health information (PHI), to provide you with this Notice of our legal duties and privacy practices, and to follow the terms of the notice currently in effect. We are required to notify you in the event of a breach of your unsecured PHI.

The following describes the ways we may use and disclose health information that identifies you without your additional authorization:

• Treatment: We may use your PHI to provide, coordinate, or manage your healthcare and related services, including sharing information with other providers involved in your care.
• Payment: We may use and disclose your PHI to obtain payment for services, including submitting claims to your insurance company and verifying coverage.
• Healthcare Operations: We may use and disclose your PHI for our internal operations, such as quality assessment, staff training, accreditation, and business management. This includes the use of AI-assisted transcription technology to support clinical documentation; the vendor operates under a HIPAA-compliant Business Associate Agreement.
• As Required by Law: We will disclose your PHI when required to do so by federal, state, or local law.
• Public Health Activities: We may disclose your PHI for public health purposes, including reporting communicable diseases or adverse events.
• Health Oversight: We may disclose your PHI to health oversight agencies for activities authorized by law, such as audits and investigations.
• Judicial and Administrative Proceedings: We may disclose your PHI in response to a court order, subpoena, or other lawful process.
• Law Enforcement: We may disclose your PHI to law enforcement officials for limited purposes permitted by law.
• Serious Threats to Health or Safety: We may use or disclose your PHI when necessary to prevent a serious and imminent threat to your health or safety or the health or safety of the public.
• Workers' Compensation: We may disclose your PHI for workers' compensation or similar programs as authorized by law.

Other uses and disclosures of your PHI not described above will be made only with your written authorization, including:

• Most uses of your PHI for marketing purposes
• Sale of your PHI
• Any other use or disclosure not described in this Notice

You may revoke an authorization in writing at any time, except to the extent we have already acted on it.

• Right to Access: You have the right to inspect and obtain a copy of your PHI. We may charge a reasonable cost-based fee. Requests must be submitted in writing.
• Right to Amend: You have the right to request that we amend your PHI if you believe it is incorrect or incomplete. We may deny the request under certain circumstances.
• Right to an Accounting of Disclosures: You have the right to request a list of certain disclosures we have made of your PHI within the past six years.
• Right to Request Restrictions: You have the right to request restrictions on how we use or disclose your PHI. We are not required to agree to your request, except in limited circumstances.
• Right to Confidential Communications: You have the right to request that we communicate with you about your PHI in a certain way or at a certain location (e.g., only by email, only at a specific phone number).
• Right to a Paper Copy of This Notice: You have the right to a paper copy of this Notice at any time, even if you have agreed to receive it electronically.
• Right to Notification of a Breach: You have the right to be notified if there is a breach of your unsecured PHI.

To exercise any of these rights, contact us at (972) 942-9972 or through our contact page.

If you believe your privacy rights have been violated, you may file a complaint with us or with the U.S. Department of Health and Human Services Office for Civil Rights. You will not be retaliated against for filing a complaint.

• ZYRA Privacy Contact: (972) 942-9972  ·  14465 Webb Chapel Rd, Suite 100, Farmers Branch, TX 75234
• HHS Office for Civil Rights: 200 Independence Ave SW, Washington DC 20201  ·  (877) 696-6775  ·  ocrportal.hhs.gov

We reserve the right to change this Notice and to make the revised Notice effective for PHI we already hold as well as new PHI we receive. The current Notice is posted on our website and is available at the clinic upon request.