Carlos E. Maas, MD, FACP, FCCP, FAASM
Fabrizio Monge, MD, FCCP, D, ABSM
Lohaliz Bobe, MD, FCCP
Edgardo Soto, MD, FCCP
Jaime Cancel, MD, FCCP
4235 Kings Highway, Suite 103 Port Charlotte, FL 33980 P 941.613.1777 F 941.613.1779
25086 Olympia Avenue, Suite 300 Punta Gorda, FL 33950 P 941.205.5300 F 941.205.5302
14942 Tamiami Trail, Unit B North Port, FL 34287 P 941.876.4415 F 941.876.4357
ACKNOWLEDGEMENT OF DISCLOSURE OF ALTERNATIVE TESTING PROVIDERS
DATE: PATIENT NAME:
I, the above named patient (or parent/custodian/legal representative) understand that my physician may
order one, or a combination of, the following diagnostic test(s), listed below:
Sleep Study/Polysomnogram/Home Sleep Test Pulmonary Function Test
Overnight Oximetry Six Minute Walk
I understand that the PRACTICE (Pulmonary Sleep & Critical Care Specialists, Accredited by the AASM)
maintains its own equipment to perform these TESTS and that my physician has or may have an investment
interest in that equipment. The PRACTICE will provide me with a list of alternate Accredited providers of
the TEST(s) in the area in which I reside, if requested. I understand that the PRACTICE is willing to order,
and I am free to obtain, the TEST(s) to be performed at any provider who maintains AASM/JCHO/ACHC
Accreditation. After carefully considering the alternatives, I hereby choose as follows:
I choose to have the PRACTICE perform and interpret the TEST(s).
I choose to have the TEST(s) performed by another provider, in which case, I agree to have the TEST
results forwarded to my physician at the PRACTICE.
PATIENT NAME (please print):
PATIENT SIGNATURE:
(or authorized representative)