Patient Information Package

Last Name*
First Name*
Middle initial
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone
Home*
Work
Cell*
Sex*
Marital Status*
S.S.N.
Employer
DOB*
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 Language
Referring Physician
Physician Name
Phone

Hidden
Patient Name and DOB
Primary Care Physician
Primary Care Physician Name
Primary Care Phone
Spouse or Parent (if minor)
Relationship
Contact telephone number
Email
Preferred Pharmacy Name
Location
Employer Information
Name of Patient's Employer
Phone
Emergency Contact
Last Name*
First Name*
Relationship to patient*
Emergency Contact's Telephone Numbers:
Home*
Work
Cell*
May we release Protected Health Information to your Emergency Contact?*
- Yes
- No

Hidden
Patient Name and DOB
Insurance Information
Insured/Uninsured Selection*
- Self Pay (No Insurance)
- Insured
Front of insurance card
An image of the front and back of all insurance cards should be uploaded.
Max. file size: 50 MB.
Back of insurance card
Max. file size: 50 MB.
Photo ID (front, eg driver’s license)
Max. file size: 50 MB.
Insurance Company (Primary)
Subscriber ID
Group Number
Relation to Insured
Subsciber Name
DOB
MM slash DD slash YYYY
S.S.N.
Insurance Company (Secondary)
Subscriber ID
Group Number
Relation to Insured
Subsciber Name
DOB
MM slash DD slash YYYY
S.S.N
Consent*
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.

Hidden
Patient Name and DOB
Medications
Please use the + button to add new lines to the list.
Medications
Medication Allergies

Hidden
Patient Name and DOB
Diagnostic Tests performed in the past
Directions: 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/year
Where
Results
Multiple Sleep Latency Test (MSLT)
- Yes
- No
Month/year
Where
Results
Maintenance of Wakefulness Test (MWT)
- Yes
- No
Month/year
Where
Results

Hidden
Patient Name and DOB
Financial Policy
Thank 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.

Hidden
Patient Name and DOB
HIPAA / ACKNOWLEDGEMENT OF RECIEPT & NOTICE OF PRIVACY PRACTICES
By 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 operations
Name
This field is for validation purposes and should be left unchanged.

Patient Information Package

Step 1 of 11

Phone

Referring Physician

Primary Care Physician

Employer Information

Emergency Contact

Emergency Contact's Telephone Numbers:

Insurance Information

MEDICAL HISTORY FORM

Medications

Health Questionnaire

Social History

Family History

Diagnostic Tests performed in the past

Epworth Sleepiness Scale

Financial Policy

HIPAA / ACKNOWLEDGEMENT OF RECIEPT & NOTICE OF PRIVACY PRACTICES