Parent Billing Information



Dear Monitoring Parent or Guardian:

Your physician has prescribed an apnea monitor for your child. This monitor has the ability to store valuable medical information that may be useful in caring for your child. This information will periodically be retrieved from the monitor by your home medical equipment supplier and forwarded for analysis and interpretation by an expert physician.

This analysis will provided by InfaScan Diagnostic Services and the interpretation provided by Dr. Andre Muelenaer, pediatric pulmonologist. This service will be billed by Dr. Muelenaer to your insurance company.

Depending on your particular policy or type of coverage, you may receive a bill from Dr. Muelenaer for the amount that your insurance policy does not cover. It is required by law that Dr. Muelenaer bill you directly for any portion not covered by your insurance. You are responsible for any portion not covered by your insurance.

If you have any questions, please call your insurance provider.

Your Email:     ***REQUIRED

Parent of Guardian  Date
Home Healthcare Provider  Date