Tampa Bay Pulmonary Associates, P.A.

 For Providers

Ashok K. Modh, M.D., F.C.C.P.

Naishadh K. Mandaliya, M.D., F.C.C.P.

Jerges J. Cardona, M.D.

Nirav B. Patel, M.D

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Microsoft Corporation or insurance company to release any information required to process my claims. ( La información anterior es verdadera a mi mejor conocimiento. Autorizo a mis beneficios de seguro a pagar directamente al medico. Entiendo que soy financieramente responsable por cualquier saldo. También autorizo a Microsoft Corporation o compañía de seguros para liberar toda la información necesaria para procesar mis reclamos. )

All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

Todas las preguntas contenidas en este cuestionario son estrictamente confidenciales. y pasarán a formar parte de su expediente médico.

Check all medical problems that other doctors have diagnosed:

(Revise todos los problemas médicos que otros médicos han diagnosticado)

Recent Changesin: Cambios recientes de:

ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE ARE OPTIONAL AND WILL BE KEPT STRICTLY CONFIDENTIAL. TODAS LAS PREGUNTAS CONTENIDAS EN ESTE CUESTIONARIO SON OPCIONALES Y SE MANTENDRÁ ESTRICTAMENTE CONFIDENCIAL.

Choose the most appropriate number for each situation over the past two weeks. Even if you don’t usually do this activity, please give your best estimate. / Utilice la siguiente escala para elegir el número más apropiado para cada situación:

0 = would never doze or sleep/No quedaría dormido 2 = moderate chance of dozing or sleeping/Probabilidad moderada de quedar dormido 1 = slight chance of dozing or sleeping/Poca probabilidad de quedar dormido 3 = high chance of dozing or sleeping/Alta probabilidad de quedar

I authorize and request Tampa Bay Pulmonary & Associates, P.A., to receive copies of medical records from any physician’s office, laboratory, and hospital that has any health information on me. The information that is being requested is needed as soon as possible in order to get the proper medical treatment I need at the time the services are rendered.

Medical Information Requested:

This information will be used to further assist in my medical care, and should be Faxed to: (813) 933-8784

This release authorizes the disclosure of records for one year from the date signed above. I understand that these records are protected under Federal and/or State law and cannot be disclosed without written consent unless otherwise provided by law. I further understand that the specific type information to be disclosed may, if applicable, include: diagnosis, prognosis, and treatment for physical and/or mental illness, including treatment of alcohol or substance abuse, auto-immune deficiency syndrome (AIDS), AIDS related complex (ARC) or human immunodeficiency virus (HIV) infection for any admissions. I understand that I have to right to revoke this consent at any time unless the facility, which is to make to disclosure of information, has already done so in reliance on the consent

2810 West Waters Ave Tampa, FL 33614 Phone (813) 935-5501 Fax (813) 933-8784 staff@mytbpa.com

Office Policy: Póliza de la oficina:

Cancellation -Patient no shows create gasp in the physician schedules that could be otherwise used to accommodate patient with urgent problems. Therefore we require a 24 hours notice of cancellation for are not notified we will charge$25for a missed appointment and$100for a missed sleep study.

Forms -The completion of forms in addition to the usual and customary insurance claim forms or prescription authorization forms represents an administrative service above and beyond the provision of medical care. The volume of these requests has increased tremendously resulting in the need for additional staff costs.Patient must set-up and appointment for completion of paper work.This includes but is not limited to FMLA forms, private disability or cancer policy forms, school or work disability or limitation forms.

Records Request -Patients are entitled to copy of their own office visit encounters and they will be furnished upon request. However, prior to your request we will need at least2 weeks in advanceto have all records requested ready.

Assignment of Benefits -I hereby authorize my insurance benefits to be paid directly to Tampa Bay Pulmonary & Associates, P.A. I understand that I am responsible for non- covered services and I authorize the release of medical information to my insurance company.

Co-pays - Co-pays and deductibles are due at the time of services. We will make every effort to make an accurate determination of patient responsibility based on your insurance plan and use of the online insurance verification service Availity.

Referrals -If you have a HMO requiring a referral or prior authorization from your Primary Care Physician.Please understand that this is the insurance plan you selected and you are responsible for obtaining the referral prior to the office visit. Failure to do so will result in inconvenience to you and the Physician and your appointment being rescheduled.

Lifetime -I authorize the release of medical information to my insurance company to process claims. I authorize this to be used as a lifetime signature to avoid the inconvenience of having to sign individual insurance claim forms at every office visit.

This notice describes how health care information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

This office uses and discloses your protected health information for the following reasons: To share with other treating health care providers regarding your health care. To submit to insurance companies claims or other payers to verify that treatment has been rendered. To verify patient’s benefits in a health care insurance plan. Release of information required by State or Federal Public Health Law. To assist in overcoming a language barrier when caring for a patient. Business associates providing written assurances that your privacy has been attained. Situations deemed emergent or medically urgent by the Physicians. Abuse, neglect, or domestic violence in accordance with State and Federal Law. Appointment reminders to household members or on answering machines. Sign-in logs may be disclosed to verify office visits. Occasional photographs and other letters and cards of appreciation from patients that are displayed.

Any other disclosures will only be made with your specific written prior authorization.

You have the right to:

Revoke authorization in writing at any time by specifying who you want restricted. Speak to our privacy officer who can be reached at 813-935-5501. Inspect copy and amend your protected health information as allowed by law. To render a complaint to our privacy office or to the Secretary of Health and Human Services.

This office reserves the right to change the terms of this notice and to make new notice provisions for all protected health information that it maintains. Patients may also get an updated copy upon request at any time by asking the staff.

I acknowledge that I have received this notice with full understanding.