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: ________________________________ Occupation: _______________________________ Street Address: ___________________________ City: __________________State: ___ Zip: _______ Emergency Contact: ________________________ Relationship: ______________________________ Street Address: ___________________________ City: __________________State: ___ Zip: _______ Home Phone: _____________________________ 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: ________________ Group Number: __________________________ Policy / ID 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
Loud or habitual snoring
Stop breathing while asleep
Excessive daytime sleepiness
Sleepiness interfering with daily activities
No
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
Unsure
Doctor’s Notes
Recently have you experienced? Yes
No
Do you currently have?
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
Past Medical History:
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
Yes
No
Yes
No
Yes
No
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
Social History:
Married
Children
Bed partner
Daily coffee cola or caffeine use
Alcohol use
Cigarette/pipe/cigar smoking
Recreational drugs
Occupation:
Family History:
Yes
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
No
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: Parents: _________________________ __________________________ Other: ___________________________
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.: ______________________ 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: ___________________ Last Name
First Name
HIPAA Privacy Notice
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
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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. T
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