SLEEP CENTER OF GREATER PITTSBURGH Scheduling Department Phone Fax

Transcription

1 Dear: SLEEP CENTER OF GREATER PITTSBURGH Scheduling Department Phone Fax This letter is to confirm your appointment for a sleep study on in our location. at Please look on the back of this page for important Insurance information!! Information about your sleep study, as well as instructions, is enclosed for you convenience. You will find questionnaires to complete. Please fill these questionnaires out, and bring them with you to your appointment. The questionnaires are an important part of your evaluation, so please be as accurate and complete as possible (you may want to ask a family member to assist you in answering some of the questions). Please bring your insurance cards, so they may be copied for our business office files. If you have an insurance that requires referrals/authorizations, please contact your primary care physician immediately so they can process your referral/authorization. Your appointment cannot proceed without this being received by the date of your study. Please check with your insurance company prior to your appointment regarding co-payments and deductibles that will be your financial responsibility! If you should become ill, please notify us immediately, even if you are keeping your appointment. Since specially trained Sleep Center staff and a room have been reserved for you, we ask that you give us a 24 hour notice if you must cancel, so that we may schedule another patient in that appointment time. Failure to give 24 hours notice may result in a cancellation fee of $ If you have any questions or concerns, please call us at Thank you! General Information What is a sleep study? A sleep study is a medical test where your behaviors during sleep are recorded and analyzed to determine if you may have a sleep disorder. About your sleep study: Prior to bedtime, you will have several small sensors applied with an electrode paste to the surface of your scalp, temples, chin, forehead, chest and legs so that we can monitor brain activity, eye movement, various muscle movements, heart rate, snoring and breathing. The process is non-invasive, safe and painless. All patients in the center are monitored so that we may observe body position and sleep behavior. It may also be necessary to videotape your activity, in which you will need to sign the consent form included in this packet. A trained sleep technologist is present in the Sleep Center for the entire study and is available if you should need assistance. You will be able to get out of bed throughout the night to use the restroom if necessary. So that we may record at least 6 hours of data, we will strive to begin your study at 11:00pm at the latest, at which time you will be asked to go to bed. Wake-up times vary due to the type of test and the individual patient sleep problems. The majority of our patients studies are complete by 6-7am. Since the Sleep Center strives to meet your schedule, please let us know if your time needs differ from those listed above. Find us on the WEB at: Locations of the Sleep Centers Monroeville # Polidora Bldg Northern Pike, Ste 201 Monroeville, PA Fax Mt. Washington* Trimont Pavilion 1301 Grandview Ave, Ste 1137-C Pittsburgh, PA Fax South Park Peter s Creek Prof. Bldg 6360 Library Road South Park, PA Fax Beaver One Beaver Place 701 Fifth Street, 3 rd Floor Beaver, PA Fax Allison Park* 4284 William Flynn Hwy Castletown Square South Ste 202 Allison Park, PA Fax Harmarville* Amberwoods Bldg 715 Freeport Road Cheswick, PA Fax Ellwood City Pine Hill Professional Bldg 310 State Route 288 Ellwood City, PA Fax Brownsville 111 Thornton Road, Ste B Brownsville, PA Fax Waynesburg* Southwest Reg. Med. Ctr 350 Bonar Avenue Waynesburg, PA Fax Butler* 110 East Diamond Street Butler PA Fax Indiana* 39 North 7 th Street Suite 1 Indiana, PA * Indicates Shower Facilities Available Indicates Facility with VCRs Only (All other facilities have DVD) # Indicates both VCR and DVD Jeannette Jefferson Medical Arts Bldg 610 Jefferson Ave, Ste #4 Jeannette, PA Fax Ross Township* 2009 Kinvara Drive Pittsburgh, PA Fax Uniontown* W & D Plaza 110 Daniel Drive Uniontown, PA Fax Delmont* 200 Brush Run Road Suite D Greensburg, PA Fax Washington* 90 West Chestnut Street Ste 135 Washington, PA Fax

2 Please note that the individual location phone numbers are only available after 8pm (if location has patients that evening). All other calls are taken at the scheduling department between 8:00am and 6:30pm M-F. Voice mail is available, and messages are returned next business day. About the Sleep Center: You will be spending 1 or 2 nights / days (Not necessarily consecutively, and depending on the outcome of the first night results) in a comfortably furnished private room. There is a television in your room. The use of cell phones is restricted after 11:00pm so that testing is not disturbed. If you do not have a cell phone, there is a telephone at the technician s desk that can be used if necessary. The Sleep Center of Greater Pittsburgh is a smoke-free environment. All facilities have outside parking at no charge. If you need assistance (wheelchair, escort, etc.) getting to the Sleep Center, please call the center prior to your study so that we can arrange for assistance. Instructions: Please read these instructions prior to your appointment 1. DO NOT Drink any alcoholic beverages whatsoever, the day of your study. 2. DO NOT Take any naps. 3. DO NOT Consume any caffeine-containing foods or beverages after 4 PM the day of your study. 4. DO maintain your usual exercise habits. 5. DO keep a record of any medications you take (including prescription and over-the-counter) on the day of your evaluation. If there are medicines or comfort measures you may need through the night, please bring them along. 6. DO Bring 2 piece pajamas, T-shirt and shorts are acceptable, but something to sleep in is mandatory other than just underwear. Robe and slippers are optional. Any personal items you will need to be comfortable. 7. DO Bring street clothing if you are scheduled for Multiple Sleep Latency Testing (MSLT daytime testing). Sleepwear is prohibited for this testing. 8. DO leave all valuable items at home. The Sleep Center cannot be held liable for any missing or damaged items. 9. DO Bring something to do between naps if you are scheduled for MSLT, as remaining in bed between naps is prohibited. You may watch TV and bring videos (MSLT tests only), as your room has a video player. 10. DO bathe before you come in for your study. Hair and skin should be free of any oils, sprays, creams or lotions. Fingernails should be free of polish or artificial coverings such as tips, in order for us to get a proper oxygen level reading. If you have artificial hair, weaves, braids, etc., please have them removed. The electrodes that are attached have to be on the scalp to get a clear reading. 11. DO notify technician of any allergies to citrus when you arrive at the lab. 12. DO fill out the questionnaire, & Epworth Sleepiness Scale enclosed in this packet and present them to the technologist upon your arrival to the Sleep Center. This information is an important part of your evaluation. If you have had any previous sleep studies elsewhere, please let us know. PLEASE CALL YOUR INSURANCE COMPANY TO CHECK IF YOU HAVE COVERAGE FOR YOUR SLEEP STUDY! We do accept most insurances, however we cannot guarantee 100% coverage by your insurance, because of co-payments, deductibles, and co-insurances. Our Corporate Name is: Sukhdev S. Grover, MD Associates d.b.a Lifecare Medical Associates & Sleep Center of Greater Pittsburgh Most Insurance Companies have us listed as: Lifecare Medical Associates or Dr. S.S. Grover The following information may be requested by your insurance when you call: Our Tax ID#: Provider ID#: AETNA Gateway Health America Health Assurance Highmark UPMC UPMC for YOU Unison Advantage Plus Choice Preferred The procedure code is: Diagnostic Sleep Study Therapeutic Sleep Study (This portion of the study will only be performed if you are diagnosed with Obstructive Sleep Apnea Diagnosis code ) While you have the insurance company on the phone you may want to ask them about Durable Medical Equipment (DME) coverage. The treatment for Obstructive Sleep Apnea (OSA - Diagnosis code or ) is either a: Continuous Positive Airway Pressure (CPAP) device DME Code: E0601 Or Bi-Level Positive Airway Pressure (BiPAP) device DME Code: E0470 If you have any questions or concerns, please do not hesitate to call us at

3 SLEEP CENTER OF GREATER PITTSBURGH SLEEP HABIT QUESTIONNAIRE NAME DATE DATE OF BIRTH Describe your problem in your own words, when and how this began and any treatments you have received: 9. Do you ever wake up gasping for breath or with a smothering sensation? 10. Do you ever wake up with heart burn or a sour taste in your mouth? 11. Do you have difficulty breathing through your nose? 12. Have you been told that you snore? 13. How many nights a week do you snore? 1. How many nights per week, on the average, have you been troubled by disturbed sleep? 2. How long has this been occurring (# years or months)? 3. Please rate the following occurrences: 1 = not really a problem 5 = a major problem a) Trouble falling asleep b) Waking up at night c) Waking up too early d) Daytime sleepiness Do you feel excessively sleepy during the day? 5. On an average night, how many hours do you sleep? 6. Do you nap? 14. Have you been told that you stop breathing while asleep? 15. Do you ever experience short periods of loss of muscle tone when Following anger or laughter? 16. Do you ever feel unable to move (paralyzed) when awakening or falling asleep? 17. Do you ever experience vivid dream-like scenes, or hear sounds upon awakening or falling asleep? 18. Do you kick in your sleep? 19. Do you experience creeping, crawling and aching sensations in your legs when trying to fall asleep? 20. Have you ever taken prescription or over the counter sleeping pills? If yes, List names of medications and when you took it: If so, how much daily? 7. Do you ever awaken with a headache? 8. Is your sleep restless? 21. Do any other members of your family have sleep problems? Please explain:

4 THE EPWORTH SLEEPINESS SCALE NAME: DATE: DATE OF BIRTH: SEX: male female How likely are you to doze off or fall asleep in the following situations? How often do you just feel tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to evaluate how they would affect you. Use the following scale to choose the most appropriate number for each situation: 0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing SITUATION CHANCE OF DOZING Sitting and reading Watching TV Sitting, inactive in a public place (e.g. a theater or meeting) As a passenger in a car for about an hour Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone Sitting quietly after lunch without alcohol In a car, while stopped in traffic for a few minutes SCORE: THANK YOU FOR YOUR COOPERATION. SLEEP CENTER OF GREATER PITTSBURGH Business office: 1704 Pittsburgh Street Cheswick, PA Permission to videotape/audiotape/audio-monitor/videomonitor I,, Patient/Guardian hereby authorize the recording of audio and/or videotapes of Name of Patient by the Sleep Center of Greater Pittsburgh with the understanding that such audio and/or videotapes may be used for medical, clinical, educational, or legal purposes. The Sleep Center of Greater Pittsburgh and associates of Sukhdev S. Grover, M.D. Associates and its duly appointed representatives are hereby released without recourse from any liability arising from the recording and use of such audio and/or videotapes. The undersigned also hereby transfers and assigns to the Sleep Center of Greater Pittsburgh the right to copy the materials in whole or in part. Signature (patient or guardian) Date Relationship to Patient if Guardian Witness Date

5 SUMMARY LIFECARE MEDICAL ASSOCIATES NOTICE OF PRIVACY PRACTICES Contact Person The name and address of the person you can contact for further information concerning our privacy practices is: LifeCare Medical Associates Attn: Privacy Officer 1704 Pittsburgh Street Cheswick, PA Effective Date This notice is effective on or after April 14, 2003 LIFECARE MEDICAL ASSOCIATES Notice of Privacy Practice THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Uses and Disclosures TREATMENT Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members. PAYMENT Your Health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated. HEALTH CARE OPERATIONS Your health information may be used as necessary to support the day-to-day activities and management of LifeCare Medical Associates. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality. LAW ENFORCEMENT Your health information may be disclosed to law enforcement agencies without your permission, to support government audits and inspections, to facilitate law enforcement investigations, and to comply with government mandated reporting. PUBLIC HEALTH REPORTING Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseased to the stat s public health department. OTHER USES AND DISCLOSURES REQUIRE YOUR ATTENTION Disclosure of your health information or its use for any purpose other than those listed above requires you specific written authorization. If you change your mind after authorizing a use or disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of you decision. Additional Uses of Information Appointment reminders Your health information well be used by our staff to send you appointment reminders Information about treatments Your health information may be used to send you information on the treatment and management of your medical condition that you may find to be of interest. We may also send you information describing other health-related goods and services that we believe may interest you.

6 Individual Rights You have certain rights under the federal privacy standards. These include: the right to request restrictions on the use and disclosure of your protected health information. the right to receive confidential communications concerning your medical condition and treatment. the right to inspect and copy your protected health information the right to amend or submit corrections to you protected health information the right to receive an accounting of how and to whom your protected health information has been disclosed. the right to receive a printed copy of this notice. LifeCare Medical Associates Duties We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We also are required to abide by the privacy policies and practices that are outlined in this notice. Right to Revise Privacy Practices As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Whatever the reason for these revisions, we will provide you with a revised notice on your next office visit. The revised policies and practices will be applied to all protected health information that we maintain. Requests to Inspect Protected Health Information As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting LifeCare Medical s Privacy officer. Complaints If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to: LifeCare Medical Associates Attn: Privacy Officer 1704 Pittsburgh Street Cheswick, PA If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concern to the same address. LIFECARE MEDICAL ASSOCIATES LifeCare Medical CONSENT FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS. CONSENT TO MEDICAL CARE I (Print Name) Understand that I will be under going a polysomnography test (sleep study). Electrodes and other sensors will be attached to my head, face, chest legs, and finger for the purpose of recording brain waves, muscle activity, respiratory airflow and effort, heart rate, and oxygen level. The tape used may cause discomfort during removal and the tape or cream used may cause redness at the site of attachment. On occasion, irregularities of heart rhythm are detected during the sleep study that may require medical attention in the doctor s office or emergency room. There are no other major risks to me from the test. During the study, I will be free to roll over in bed, but will have to ask for assistance to get out of bed. I acknowledge that no guarantees have been given to me as to the outcome of any examination or treatment and all results of the testing and / or treatment are kept confidential. I understand the reason for the test and the procedure has been explained to me. I also understand and agree that others, under the direction of the physician involved in my care, may assist or participate in providing medical care. I give LifeCare Medical Associates and its designee s permission to use recorded data for scientific, educational or other purposes. I (Print Name) hereby authorize the recording of video and/or audio with the understanding that such video and/or audio may be used for medical, clinical, educational, or other purposes. LifeCare Medical Associates and associates of Sukhdev S. Grover, M.D. Associates and its duly appointed representatives are hereby released without recourse from any liability arising from the recording and use of such video and/or audio recordings. The undersigned also hereby transfers and assigns to LifeCare Medical Associates the right to copy the materials in whole or part. Patient Signature Date Signature on behalf of patient/relationship Date Signature of LifeCare Representative Date You will not be penalized or otherwise retaliated against for filing a complaint.

7 FINANCIAL ARRANGEMENTS/RELEASE OF INFORMATION I agree to the following terms of payment for services provided: 1a.) I authorized LifeCare Medical Associates to bill my insurance carrier and request such payments to be made directly to LifeCare Medial Associates. I certify that the information I have given about my insurance coverage or other payment sources is correct. 1b.) I assign LifeCare Medical Associates all rights to insurance payments or benefits to which I may be entitled for services provided to me by LifeCare Medical Associates. 1c.) I authorized LifeCare Medical Associates to release any medical or other information about this visit or service, if required to obtain payment from my insurer or other payer. I also authorized LifeCare Medical Associates to release any medical or other information required by my insurer, other payers, and government agencies or their designees for review of the care provided. 2. I assign all rights of benefits, insurance proceeds, settlements payments or judgments to which I may be entitled for physician services for interpretation of laboratory, pathology, radiology, neurology, cardiology, diagnostic test, anesthesiology and/or emergency room services to the physician or organization providing the service. I also authorize submission of a claim for payment on my behalf to my insurance carrier. 3. I consent to LifeCare Medical Associates to access medical or other information maintained on electronic information systems or stored in various forms at individual LifeCare Medical affiliates related to treatment and/or services provided by LifeCare Medical Associates or any affiliates in connection with my care or payment for treatment and services. I also authorize information related to my care to be provided to my primary care/family physician(s) and such persons as necessary for them to provide consultation, treatment and/or services to me. 4. I authorize the release of information if required by local, state or federal law. 5. Sensitive Information (When applicable) I consent to and authorize the release of my sensitive medical or other information (for example: Behavioral Health, HIV and Drug & Alcohol) to bill my insurance carrier(s), to other payers and to government agencies or their designees for review of the care provided. Additionally, with respect to any drug and alcohol related information, disclosure of such information about me shall be restricted to whether of not I am in treatment, my prognosis, the program structure, treatment model and services offered to me, a brief description of my progress and a short statement as to whether I have relapsed into drug and alcohol abuse and the frequency of any such relapses and other information permitted under 4Pa Code Section 255.5(b) 6. I understand that any amounts not paid by my insurance are my responsibility. This includes non-covered services, co-insurances, co-pays and yearly deductibles. (required) Patient signature Medicare Certification I certify that the information given to me in applying for payment under Title XIX of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Centers for Medicare and Medicaid or its intermediaries or carriers, any information needed for this or a related Medicare Claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for physician services to the physician or organization providing the services or authorize that physician or entity to submit a claim to Medicare for payment to me. Medicaid Certification I certify that the information given on this consent is true, correct and accurate. I understand that payment and satisfaction of this claim will be from federal and state funds and that any false claims, statements, documents or concealment of material facts, may be prosecuted under applicable federal and state laws. Patient Signature Date LifeCare Representative Date Consent to Use and Disclosure of Protected Health Information Use and Disclosure of Your Protected Health Information Your protected health information will be used by LifeCare Medical Associates or disclosed to others for the purposes of treatment, obtaining payment, or supporting the day-to-day health care operations of the practice. Notice of Privacy Practices You should review the Notice of Privacy Practices for a more complete description of how your protected health information may be used or disclosed. You may review the notice prior to signing this consent. Requesting a Restriction on the Use or Disclosure of Your Information You may request a restriction on the use of disclosure of your protected health information. LifeCare Medical Associates may or may not agree to restrict the use or disclosure of your protected health information.

8 If LifeCare Medical Associates agrees to your request, the restriction will be binding on the practice. Use or disclosure of protected information in violation of an agreed upon restriction will be a violation of the federal privacy standards Revocation of Consent You may revoke this consent to the use and disclosure of your protected health information. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent to received will not be affected. Reservation of Right to Change Privacy Practices LifeCare Medical Associates reserves the right to modify the privacy practices outlined in the notice. Signature I have reviewed this consent form and give my permission to LifeCare Medical Associates to use and disclose my health information in accordance with it. Name of Patient (print or type) Signature of Patient Date Signature of Patient Representative Relationship of Patient Representative to Patient