Patient Registration/ Information Sheet Name: Last First Middle Date of Birth: Gender: F M Marital Status: Social Security Number: Street Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Ethnicity: Race: Language: Employment Status: Employer: Street Address: Occupation: City: State: Zip: Emergency Contact: Street Address: Home Phone: Relationship: City: State: Zip: Cell Phone: Work Phone: May we email you information from time to time? Yes No If yes, can you please provide us your email address? Your information will be used for Sleep Center Orange County purposes only and will not be provided to any other sources without express permission. Person Responsible for charges: Relationship: Contact Number: Address (if different): City: State: Zip: Primary Insurance: HMO POS/PPO Medicare Cash Other Insurance Company Name: Group Number: Policy / ID Number: Primary Insurance Subscriber: Relationship: Date of Birth: Secondary Insurance: HMO POS/PPO Medicare Cash Other Insurance Company Name: Policy / ID Number: Group Number: Whom may we thank for referring you to our Practice? Treating Physicians: I hereby assign my insurance benefits to be made directly to my physician and any assisting physicians, for services rendered. I hereby attest that the above insurance information is accurate and that I am an eligible member and understand that I am responsible for knowing my benefits / coverage and tests ordered by my physician may NOT be covered. I will be financially responsible for all charges that are not covered by my insurance company. I also hereby authorize the release of all information to other physicians and insurance carriers upon request for the purpose of payment for the medical services and further treatment of care by another physician. I further agree that a photocopy of this agreement shall be valid as the original. Payment is due at the time services are rendered. All charges are the direct responsibility of the patient. Sleep Center Orange County, Inc. cannot render service on the assumption that the charges will be paid by the Insurance Company. Insurance is an agreement between you and your insurance company. If Sleep Center Orange County, Inc. has problem collecting payment from you, we will also add attorney s fees, collection agency costs and any related fees to your bill. I hereby acknowledge that I have read, understand and agree to hereby give consent for treatment. Patient Signature: Date:
Sleep Clinic New Patient Questionnaire Name: Date: Date of Birth: Reason for your visit to the sleep clinic: Please give this questionnaire to your healthcare provider who will clarify and review this questionnaire with you in detail. Current complaint: (please check answer) Yes No Unsure Loud or habitual snoring Stop breathing while asleep Excessive daytime sleepiness Sleepiness interfering with daily activities Doctor s Notes Decreased energy/fatigue during the day Unrefreshing sleep Morning headaches Frequent awakenings from sleep Choking or snorting while asleep Short of breath during sleep Sweating while asleep Difficulty breathing on your back Daytime naps / dozing Sleep walk Sleep talk Act out dreams (kick, punch, scream etc.) Hallucinations prior to falling asleep Feel paralyzed just before falling asleep Kick / move your legs while asleep Sudden muscle weakness when emotional Grind teeth while asleep Leg restlessness (crawling, aching feeling) Difficulty falling asleep Difficulty staying asleep Use sleeping medication Anxiety / racing thoughts prior to sleep Sour or acid taste in mouth at night Body pain at night Weight changes over last two years Nasal Congestion at night Bed time: Out of bed time: Other complaint / concerns Page 1 of 2
Recently have you experienced? Yes Double vision or vision changes Headache Sinus congestion or pain Chest pain Irregular heart beats Shortness of breath at rest Cough Blood in your stool Bed wetting Heat or cold intolerance Abdominal pain Diarrhea Nausea/ vomiting Loss of consciousness (not sleep) Heart burn Shortness of breath with exertion Memory Loss No Do you currently have? Yes No Feelings of sadness Feelings of guilt Loss of interest in usual hobbies Decreased concentration Change in appetite Change in sleeping pattern Feelings of moving slow This Space for Doctor s Notes Past Medical History: Yes No Sleep apnea High blood pressure Seizure or Epilepsy Diabetes Stroke / TIA Heart disease/irregular heart beat Asthma/COPD/Lung disease Parkinson s disease Depression/Anxiety/Mood disorder Iron deficiency Cancer Any surgeries Other: Current Medications: Medication allergies Yes No Social History: Yes No Married Children Bed partner Daily coffee cola or caffeine use Alcohol use Cigarette/pipe/cigar smoking Recreational drugs Occupation: Family History: Yes No Sleep apnea Stroke Diabetes Heart disease Other sleep disorder The above information is true to the best of my knowledge. Signature: Page 2 of 2
Last Name First Name Cancellation / No Show Policy Most people are considerate in providing us with advance notice to allow us to make the time available for other patients who need appointments. This policy is in place due to the unfortunate fact that we continue to encounter some patients who cancel at the last minute. We are making every effort to be up front and clear about our cancellation policy so there is no misunderstanding. Please keep in mind that unlike a lot of other medical offices, we do not double book appointment slots. We reserve a time block for each individual patient, a time that is set aside only for you and your care. Cancellations, rescheduling, and not showing for follow up appointments require a minimum of 24 hours Business Day notice to cancel appointments. If you do not give us advance notice to cancel or reschedule your appointment (new or follow-up), a $25.00 fee will be charged. Because a large block of time is reserved for you, cancellation or rescheduling of Sleep Study appointments requires a minimum of two business days (48 hours) notice IN ADVANCE to avoid a fee. A $300.00 fee will be charged for any sleep study cancelled less than the required notice. A voice mail message left after business hours is not acceptable. Our regular business hours are Monday-Friday, 9:00AM-5:00PM. We certainly understand that situations arise and patients need to change appointments. We are happy to work with you to reschedule appointments. All we ask is that you give us enough advance notice. We sincerely appreciate your consideration and cooperation. By signing below, I acknowledge that I have read and accept the above cancellation policy. Signature Date Printed Name Relationship to patient
I understand that I am being evaluated for a sleep disorder that can cause sleepiness during the daytime, as well as, in the evening hours. I understand the safety risks of sleepiness, especially when I am driving or doing anything that requires my attention and alertness. I understand that if I drive while sleepy, I may cause injury to myself and others. I will refrain from driving when sleepy and otherwise adjust my activities until my sleepiness has resolved. I know that if I have any other questions about the safety risks of my condition, I can call the clinic and discuss them. By signing below, I agree to the above statements. Patient Name DOB Signature of Patient/Guardian Date 4980 Barranca Parkway, Suite 170, Irvine, CA 92604 Tel: (949) 679-5510 Fax: (949) 679-1080
Last Name First Name Consent Form for Medical Information Disclosures Sleep Center Orange County, Inc. Wesley Elon Fleming, M.D., and employees / independent contractors who provide healthcare services Armaghan Azad, M.D., MPH. and employees / independent contractors who provide healthcare services In connection with the medical services that I am receiving from the above- named physician/provider, I hereby authorize the above- named physician/provider to disclose any or all information concerning my medical condition and treatment, including copies of applicable hospital and medical records to: A. Any third party payor covering the medical services of the patient B. Other health care professionals and institution involved in the delivery of health care to the patient C. The proponent of any legally sufficient subpoena, or in response to a court order D. Employees and agents of the practice, to the degree necessary to facilitate the provision of health care services and payment for such services E. Pharmacies F. Other parties as otherwise required by the law. In each case, the practice shall take reasonable steps to ensure that only the minimum necessary information is disclosed in accordance with the above. I am consenting to receive my medical information by the following communication method- Please check all that apply: Telephone conversation Telephone message on my home answering machine. Home Phone Number: Telephone message on my office voicemail. Work Phone Number: Leave telephone message with: (name of individuals who are authorized to receive you medical information by phone) Telephone message on my cell phone. Mobile Phone Number: I consent to have my medical information discussed with: Please check all that apply and include name: Spouse: Children: I consent to have my medical information shared with my physicians: Please check and fill in all that apply: Primary Physician: Other M.D.: Parents: Other: Other M.D.: Other M.D.: This consent is valid from the date executed until revoked in writing by the patient. Signature: Date: If person other than patient is signing, please print full name and indicate relationship below. Print Full Name: Relationship:
HIPAA Privacy Notice Last Name First Name In accordance with the Health Insurance Portability and Accountability Act of 1996, patient of this practice are entitled to the greatest degree of privacy possible. This office will strive to ensure that patient information is used only for authorized purposes as agreed to by the patient. Patients are advised that they have a right to review their medical files upon reasonable notice to the practice during normal business hours, and to make comments to the same. Patients have the right to direct the methods of communication of their medical information and to specify the individuals to whom that wish their medical information released to, in addition to those indicated on the consent for medical information disclosure form. Practice Policy and Procedures Before any records are released, staff will review to ensure that the release has been authorized by the patient or is otherwise permitted. Before any records are released, staff will review to ensure that only the information necessary has been released. Only members of the staff shall have access to medical records. Staff members shall have access limited to portions of the records directly related to their duties (for example, the secretary shall have access to the pharmacy records for the purpose of refilling prescriptions). At the close of the business each day, all computers containing medical information shall be secured and logged off of or placed in the physician s office. Each patient chart shall include records of all releases of information, including the date, to whom the information was sent and the material included. Oral PHI (Protected Health Information) should not be communicated in general patient areas. All discussion regarding patient care shall be conducted either in the patient s examination room or in the physician s private office. In emergencies, other arrangements may be made on a case by case basis. Oral PHI should not involve unnecessary parties. Discussions concerning patients should never be made in another patient s examination room. Common area conversations concerning patients are to be avoided. Out-of-office conversations regarding PHI are forbidden. Parents and Minors Only the parent or legal guardian of a child has a right to access records. Exceptions include: State law pre-emption (e.g., applicable state law concerning pregnancy or sexually transmitted diseases) Court order Potential abuse or neglect With parent or guardian consent Receipt of Privacy Notice By signing below, I confirm that I have received and read the privacy notice given to me in accordance to HIPPA. Signature: Date: If person other than patient is signing, please print full name and indicate relationship below. Print Full Name: Relationship: Any question regarding this privacy notice should be directed to this practice s HIPPA compliance officer, Ms. Ellen Miller. Phone: (949) 679-5510 Ext. 4
A MESSAGE TO OUR PATIENTS REGARDING ARBITRATION AGREEMENTS The Physicians of Sleep Center Orange County, Inc. use binding arbitration agreements as a process that will be mutually beneficial to everyone. Arbitration is the process of resolving disputes in front of a panel of neutral arbitrators. Binding arbitration has proven to be a more flexible and cost efficient way to resolve disputes. It lessens the intensity of a jury trial and offers a speedier resolution for both parties. We ask that you read the information provided on the arbitration document and sign the form. Your signature indicates that you have read and understand this information. The Physicians and staff of Sleep Center Orange County, Inc. thank you for choosing us as your medical providers and are committed to proving the high quality care and service you deserve. The Physicians of Sleep Center Orange County, Inc. exercise the right to require signed arbitration agreements from all patients who elect to have medical services, testing, etc. provided to them at our facility. If you choose to NOT sign the arbitration agreement, we are happy to refer you back to your primary care physician, referring physician, or another facility.
THISISASAMPLEDOCUMENT PROVIDEDFORYOURREVIEW ONLY. SAMPLE ORIGINALWILLBEPROVIDEATTHEOFFICE ANDWILLREQUIREYOURSIGNATURE.