Patient Information Package Step 1 of 11 9% Last Name*First Name*Middle initialEmail* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneHome*WorkCell*Sex*Marital Status*S.S.N.EmployerDOB* MM slash DD slash YYYY Age*Race* American Indian / Alaskan Native Asian Black / African American Native Hawaiian / Pacific Islander White Refuse to Report Ethnicity* Hispanic / Latin Non Hispanic / Latin Refuse to Report Preferred LanguageReferring PhysicianPhysician NamePhone This field is hidden when viewing the formPatient Name and DOBPrimary Care PhysicianPrimary Care Physician NamePrimary Care PhoneSpouse or Parent (if minor)RelationshipContact telephone numberEmail Preferred Pharmacy NameLocationEmployer InformationName of Patient's EmployerPhoneEmergency ContactLast Name*First Name*Relationship to patient*Emergency Contact's Telephone Numbers:Home*WorkCell*May we release Protected Health Information to your Emergency Contact?* Yes No This field is hidden when viewing the formPatient Name and DOBInsurance InformationInsured/Uninsured Selection* Self Pay (No Insurance) Insured Front of insurance cardAn image of the front and back of all insurance cards should be uploaded.Max. file size: 50 MB.Back of insurance cardMax. file size: 50 MB.Photo ID (front, eg driver’s license)Max. file size: 50 MB.Insurance Company (Primary)Subscriber IDGroup NumberRelation to InsuredSubsciber NameDOB MM slash DD slash YYYY S.S.N.Insurance Company (Secondary)Subscriber IDGroup NumberRelation to InsuredSubsciber NameDOB MM slash DD slash YYYY S.S.NConsent*I am responsible for providing up to date and accurate insurance information to Capitol Sleep Medicine, LLC. I certify the information given by me in applying for payment under Title XVIII of the Social Security Act (Medicare) or under the terms of any other insurance carriers is correct. If your insurance changes I will notify Capitol Sleep Medicine within 10 days of this change. I understand that failure to do so may result in me being billed for any outstanding balances. I hereby authorize Capitol Sleep Medicine, LLC and / or any of its representatives to submit claims to my insurance carrier or its intermediary for services rendered to me and authorize payment be made directly to Capitol Sleep Medicine, LLC. I hereby authorize release of any information necessary to process medical claims. I authorize release of medical information necessary for continuity of care to Home Medical Equipment companies as recommended by my medical provider. I understand that my insurance carrier will assign benefits to Capitol Sleep Medicine, LLC. I understand and certify that I am financially responsible for all health care service charges that are paid to me directly by my insurance carrier as well as for any applicable copayments, coinsurance, deductibles, and / or charges for non covered goods and services provided to me or to any of my dependents. I will pay any and all charges due and owing Capitol Sleep Medicine, LLC in accordance with their regular rates, terms, and policies. By signing below I certify that I will pay to Capitol Sleep Medicine, LLC any copayments, coinsurance, deductibles, or non covered goods and services. I will immediately pay to Capitol Sleep Medicine, LLC any payments I receive from my insurance for services provided by them to me or my dependents. I will also be responsible for any amounts not paid by my insurance due to my failure to provide Capitol Sleep Medicine, LLC appropriate insurance information for billing. I agree to the privacy policy. This field is hidden when viewing the formPatient Name and DOBMEDICAL HISTORY FORMCARDIOVASCULAR Angina/coronary disease Cardiac Rhythm disturbance Stroke Heart attack Heart failure High blood pressure ENDOCRINE Diabetes and taking insulin Diabetes and not taking insulin Hypothyroidism (under active thyroid) Hyperthyroidism (overactive thyroid) Other Type of other endocrine conditionGASTROENTEROLOGY Esophagitis/heartburn/hiatus hernia/ulcer Other Type of other gastroenterology conditionRESPIRATORY Obstructive Sleep Apnea Asthma Emphysema Bronchitis / COPD Other Type of other respiratory conditionINFECTIOUS DISEASE Pneumonia Other Type of other Infections DiseaseMUSCULOSKELETAL Restless Legs Syndrome Scoliosis/ kyphoscoliosis NEUROLOGY Migraine headaches Dementia Seizures, convulsions Multiple Sclerosis Other Type of other neurology conditionPSYCHIATRY Insomnia Depression Bipolar Disorder EAR, NOSE AND THROAT Deviated Nasal Septum Sinusitis / Nasal Polyps Other Type of other ear, nose and throat conditionSURGICAL HISTORY Tonsillectomy Oropharyngeal Surgery Nasal Surgery Bariatric Surgery Other Type of other surgical history This field is hidden when viewing the formPatient Name and DOBMedicationsPlease use the + button to add new lines to the list.Medications Medication Allergies This field is hidden when viewing the formPatient Name and DOBAny history of smoking? Yes No Any history of smoking? Yes No Health QuestionnaireAny Daytime Sleepiness? Yes No Level of sleepiness Mild Moderate Severe Night Sweats? Yes No Any changes in your weight in the last year more then 15 LBS? Yes No If weight changes more than 15lbs I have gained weight I have lost Weight How much weight?Any frequent headaches? Yes No Type of headache Tension? Migraine? Vision affected by headache? Yes No if yes, Nausea? Vomiting? Sinus problems? Yes No Any Shortness of breath? Yes No Coughing? Yes No Wheezing? Yes No Chest Pain? Yes No Heart palpitation/ irregular heart beat? Yes No Frequent urination more than 3 times a night? Yes No Any arthritis/ backaches? Yes No Numbness/tingling in arms or legs? Yes No Depression? Yes No Anxiety? Yes No Irritability? Yes No Problems with insomnia? Yes No This field is hidden when viewing the formPatient Name and DOBSocial HistoryCurrent smoker? Yes No How much are you smoking a day or how much did you smoke a day?Any alcohol? Yes No How often do you drink alcohol? Often Rare Social Any caffeine intake? Yes No How much caffeine a day?Are you currently working? Yes No Are you a commercial driver? Yes No Family HistoryAnyone with sleep apnea? Yes No Narcolepsy? Yes No Stroke? Yes No Heart attack? Yes No High blood pressure? Yes No Other family history This field is hidden when viewing the formPatient Name and DOBDiagnostic Tests performed in the pastDirections: Please check in all that apply as completely as possible. If the answer os yes on any of the studies fill the Month/year, Where and Results fields. This information may prevent unnecessary duplication of diagnostic studies. If you have not had a particular test, check 'No'All-night sleep study Yes No Month/yearWhereResultsMultiple Sleep Latency Test (MSLT) Yes No Month/yearWhereResultsMaintenance of Wakefulness Test (MWT) Yes No Month/yearWhereResults This field is hidden when viewing the formPatient Name and DOBEpworth Sleepiness ScaleHow likely are you to doze off or fall asleep in the following situations, in contrast to just feeling 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 work out how they would have affected 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 dozingSitting and reading 0 1 2 3 Watching television 0 1 2 3 Sitting inactive, in a public place, e.g. in a meeting… 0 1 2 3 As a passenger in a car for an hour without a break 0 1 2 3 Lying down in the afternoon when circumstances permit 0 1 2 3 Sitting and talking to someone 0 1 2 3 Sitting quietly after lunch without alcohol 0 1 2 3 In a car while stopped for a few minutes in traffic 0 1 2 3 Total Score This field is hidden when viewing the formPatient Name and DOBFinancial PolicyThank you for Capitol Sleep Medicine, LLC the opportunity to participate in your health care. We are committed to providing quality service. 1. It is your responsibility to have provided us with up to date insurance information. In addition to your insurance card we will ask for your photo ID. You will be responsible for any amounts not paid by your insurance because you have not provided appropriate insurance information to Capitol Sleep Medicine, LLC. 2. You must complete and sign any required information sheets and/or payment agreement forms before seeing the doctor or receiving service from our practice. 3. It is your responsibility to understand your insurance benefits, obtaining proper authorization for services, and submit referral claim forms if necessary. 4. Many insurance plans require patients to pay a co-payment, deductible, or co-insurance amount. It is your responsibility to understand any applicable co-payments, co-insurances, and deductibles. Please come to your appointment prepared to pay your co-payment. 5. If you have no insurance or if Capitol Sleep Medicine does not participate in your insurance plan, payment in full is required prior to receiving goods and services. 6. Insurance benefits are the result of the contract with your insurance company. If your insurance plan does not pay our bill within sixty days after billing, or your claim is denied, you will receive a statement from Capitol Sleep Medicine, LLC indicating that the bill is now your responsibility. Patient balances are billed upon receipt of your insurance plan's explanation of benefits (EOB). Your payment is due within ten business days of your receipt of our bill. 7. Capitol Sleep Medicine, LLC requires at least forty eight (48) hours notice for cancelling a sleep study appointment. Failure to provide timely notice of cancellation for a sleep study may result in a cancellation fee of $150.00. 8. Checks written to Capitol Sleep Medicine that are returned by your bank due to insufficient funds will incur a $50 penalty. Other Items: 1. Security is a priority for Capitol Sleep Medicine, LLC. We have a security system for our building. At the Grove City location we have security cameras as well monitoring the parking lots. Nevertheless, it is possible that theft or damage to your personal property may occur while parking on our property. Capitol Sleep Medicine claims no responsibility for loss or damage to personal property while parked in our parking lots. You hereby release Capitol Sleep Medicine LLC from any and all claims from liability from any loss or damage to personal property that occurs on our premises. 2. If you take any medications you should check with your physician as to whether you should take them on the day of your study. If the physician has given you a prescription for a sleep aid, please bring this medication with you. The sleep technicians do not dispense medications to patients. Please be aware that medications you may take to help you sleep in the sleep lab may cause drowsiness, and in this case it is your responsibility to arrange for a ride home after your study. Consent* I AGREE TO COMPLY FULLY WITH ALL POLICIES AS DETAILED ABOVE. This field is hidden when viewing the formPatient Name and DOBHIPAA / ACKNOWLEDGEMENT OF RECIEPT & NOTICE OF PRIVACY PRACTICESBy signing the following you are giving Capitol Sleep Medicine LLC permission to use and disclose your protected health information in accordance with the directives listed below: Consent to HIPAA / ACKNOWLEDGEMENT OF RECIEPT & NOTICE OF PRIVACY PRACTICES* I declare that I understand and have been provided with a notice of information practices that provides me a more complete description of information uses and disclosures. I understand that I have the following rights and privileges** The right to review the notice prior to signing this consent * The right to object to the use of my health care information for directory purpose * The right to request restrictions as to how my health care information may be used or disclosed in this office to carry out treatment, payment, or health care operationsEmailThis field is for validation purposes and should be left unchanged.
