Office and Insurance Policies

Insurance Policy:

Payments of our fees are your responsibility and are due in full at the time of service. As a courtesy to you, we will verify benefits and file our charges with your insurance carrier. The guarantor and/or patient agree to:

1. Verification of coverage and benefits is not a guarantee of payment. The information provided to us by your insurance company may be inaccurate. It is the patient's responsibility to clarify this information with their insurance.
2. On day of service, or prior to any tests/procedures, pay any portion of our fees that are not covered by the insurance company, which may include a) copays; b) coinsurance and c) unmet deductible portions (you will not be balance billed for uncovered portions of our contracted rates unless they fall into one of the categories mentioned above.
3. Respond to requests from their insurance company for additional information in order to process claim(s).
4. Monitor claims filed with the insurance company by reviewing the "Explanation of Benefits" (EOB's) received from the insurance company, and by calling to check the status of outstanding claims.

Financial Agreement/Assignment of Benefits:

• As the responsible party (guarantor and/or patient}, I hereby assign to Sleep Medicine Specialists of California (physician practice), any and all payments of health insurance benefits and all interest and rights {including causes of action and the right to enforce payment) for services rendered under any insurance policies or any reimbursement or prepaid health care plan. If my condition was caused by events, which result in legal action, I assign to the physician practice an interest in any claims I may have. I hereby promise to pay for all services rendered to me to the extent I am legally responsible for such payment; I understand I am financially responsible tor all health insurance deductibles, co-payments, coinsurance, and any services not covered by my insurance policy. I also agree to accept the terms listed above.

No Show/Cancellation Policy:

• I agree to pay $25 cancellation fee for appointments I fail to reschedule or cancel within 24 hours. If I do not show for an appointment without notice, I agree to pay $75 no show fee.

Returned Checks/Not Sufficient Funds:

• I hereby agree that Sleep Medicine Specialists of California may charge and collect a $25 fee for returned check due to insufficient funds in my bank account.

Electronic Signature: I hereby agree that my typed name on all online forms I fill out and submit for Sleep Medicine Specialists of California serves as my legal and valid signature.

I hereby authorize BASS Medical Group to apply for benefits and submit insurance claims for reimbursement on my behalf for covered services rendered. They may also disclose any or all parts of my clinical record to any insurance company covering services for the purpose of satisfying charges billed. I also understand that if any insurance payments are sent to me directly, it is my responsibility to send them to BASS Medical Group immediately upon receipt. I, the patient, or the patient’s representative, understand that all medical doctors at BASS Medical Group are licensed and regulated by the Medical Board or California. I can verify this by contacting the Medical Board at (800) 633.2322 or via internet website: http://www.mbc.ca.gov.I further agree to pay collection costs, attorney fees and any other collection costs that may be incurred in the attempt to collect outstanding patient responsibility amounts.

Summary of Patients’ Rights and Responsibilities

We are committed to serving you with compassion, care, skill, and respect. We do not discriminate on the basis of sex, age, creed, race or national origin. As one of our patients, you have choices, rights and responsibilities.

You have the RIGHT:

• to be treated with dignity and respect
• to know the names and professional status of people serving you 
• to privacy
• to confidentiality of your records
• to receive accurate information about your health-related concerns
• to know the effectiveness, possible side effects and problems of all forms of treatment
• to participate in choosing a form of treatment
• to receive education and counseling
• to consent to, or refuse, any care or treatment
• to select and/or change your health care provider
• to review your medical records with a clinician
• to file a concern or grievance
• to fair and humane treatment
• to information about services and any related costs
• to self determination; including the right to make choices about life-sustaining treatment

You also have the RESPONSIBILITY:

• to seek medical attention promptly
• to be honest about your medical history
• to ask about anything you do not understand
• to follow health advice and medical instructions
• to report any significant changes in symptoms or failure to improve
• to respect clinic policies
• to keep appointments or cancel in advance
• to seek non-emergency care during regular business hours
• to provide useful feedback about services and policies

Informed Consent of Telemedicine Services

Telemedicine involves the use of electronic communicationsto enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following: Patient medical records, Medical images, Live two-way audio and video, Output data from medical devices and sound and video files.

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:

• In rare cases, the consultant may determine that the transmitted information is of inadequate quality, thus necessitating a face-to-face meeting with the patient, or at least a rescheduled video consult;
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
• In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors;

1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine, which identifies me, will be disclosed to researchers or other entities without my written consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
3. I understand the alternatives to telemedicine consultation as they have been explained to me, and in choosing to participate in a telemedicine consultation, I understand that some parts of the exam involving physical tests may be conducted by individuals at my location, or at a testing facility, at the direction of the consulting healthcare provider.
4. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
5. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
6. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes (such as office staff as typically done for an office visit)

I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction.

Notice of Privacy Practices

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

This practice uses and discloses health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive.This notice describes our privacy practices. You can request a copy of this notice at any time.

Treatment, Payment, Health Care Operations:

Treatment

We are permitted to use and disclose your medical information to those involved in your treatment. When we provide treatment, we may request that your primary care physician share your medical information with us. Also, we may provide your primary care physician information about your particular condition so that he or she can appropriately treat you for other medical conditions, if any. If your care requires the involvement of another specialist, when we refer you to a specialist, we will share some or all of your medical information with that physician to facilitate the delivery of care.

Payment

We are permitted to use and disclose your medical information to bill and collect payment for the services provide to you. For example, we may complete a claim form to obtain payment from your insurer or HMO. The form will contain medical information, such as a description of the medical service provided to you, that your insurer or HMO needs to approve payment to us.

Health Care Operations

We are permitted to use or disclose your medical information for the purposes of health care operations, which are activities that support this practice and ensure that quality care is delivered. For example, we may engage the services of a professional to aid this practice in its compliance programs. This person will review billing and medical files to ensure we maintain our compliance with regulations and the law. For example, we may ask another physician to review this practice’s charts and medical records to evaluate our performance so that we may ensure that only the best health care is provided by this practice.

Disclosures That Can Be Made Without Your Authorization

There are situations in which we are permitted by law to disclose or use your medical information without your written authorization or an opportunity to object. In other situations we will ask for your written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization, in writing, to stop future uses and disclosures. However, any revocation will not apply to disclosures or uses already made or taken in reliance on that authorization.

Public Health, Abuse or Neglect, and Health Oversight

We may disclose your medical information for public health activities. Public health activities are mandated by federal, state, or local government for the collection of information about disease, vital statistics (like births and death), or injury by a public health authority. We may disclose medical information, if authorized by law, to a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition. We may disclose your medical information to report reactions to medications, problems with products, or to notify people of recalls of products they may be using. We may also disclose medical information to a public agency authorized to receive reports of child abuse or neglect. California law requires physicians to report child abuse or neglect. Regulations also permit the disclosure of information to report abuse or neglect of elders or the disabled. We may disclose your medical information to a health oversight agency for those activities authorized by law. Examples of these activities are audits, investigations, licensure applications and inspections which are all government activities undertaken to monitor the health care delivery systemand compliance with other laws, such as civil rights laws.

Legal Proceedings and Law Enforcement

We may disclose your medical information in the course of judicial or administrative proceedings in response to an order of the court (or the administrative decision-maker) or other appropriate legal process. Certain requirements must be met before the information is disclosed.

If asked by a law enforcement official, we may disclose your medical information under limited circumstances provided that the information:

• Is released pursuant to legal process, such as a warrant or subpoena;
• Pertains to a victim of crime and your are incapacitated;
• Pertains to a person who has died under circumstances that may be related to criminal conduct;
• Is about a victim of crime and we are unable to obtain the person’s agreement;
• Is released because of a crime that has occurred on these premises; or
• Is released to locate a fugitive, missing person, or suspect.

We may also release information if we believe the disclosure is necessary to prevent or lessen an imminent threat to the health or safety of a person.

Workers’ Compensation

We may disclose your medical information as required by the California workers’ compensation law.

Inmates

If you are an inmate or under the custody of law enforcement, we may release your medical information to the correctional institution or law enforcement official. This release is permitted to allow the institution to provide you with medical care, to protect your health or the health and safety of others, or for the safety and security of the institution.

Military, National Security and Intelligence Activities, Protection of the President

We may disclose your medical information for specialized governmental functions such as separation or discharge from military service, requests as necessary by appropriate military command officers (if you are in the military), authorized national security and intelligence activities, as well as authorized activities for the provision of protective services for the President of the United States, other authorized government officials, or foreign heads of state.

Research, Organ Donation, Coroners, Medical Examiners, and Funeral Directors

When a research project and its privacy protections have been approved by an Institutional Review Board or privacy board, we may release medical information to researchers for research purposes. We may release medical information to organ procurement organizations for the purpose of facilitating organ, eye, or tissue donation if you are a donor. Also, we may release your medical information to a coroner or medical examiner to identify a deceased or a cause of death. Further, we may release your medical information to a funeral director where such a disclosure is necessary for the director to carry out his duties.

Required by Law

We may release your medical information where the disclosure is required by law.

Your Rights Under Federal Privacy Regulations

The United States Department of Health and Human Services created regulations intended to protect patient privacy as required by the Health Insurance Portability and Accountability Act (HIPAA). Those regulations create several privileges that patients may exercise. We will not retaliate against a patient that exercises their HIPAA rights.

Requested Restrictions

You may request that we restrict or limit how your protected health information is used or disclosed for treatment, payment, or healthcare operations. We do NOT have to agree to this restriction, but if we do agree, we will comply with your request except under emergency circumstances.

To request a restriction, submit the following in writing: (a) The information to be restricted, (b) what kind of restriction you are requesting (i.e. on the use of information, disclosure of information or both), and (c) to whom the limits apply. Please send the request to the address and person listed below.

You may also request that we limit disclosure to family members, other relatives, or close personal friends that may or may not be involved in your care.

Receiving Confidential Communications by Alternative Means

You may request that we send communications of protected health information by alternative means or to an alternative location. This request must be made in writing to the person listed below. We are required to accommodate only reasonable requests. Please specify in your correspondence exactly how you want us to communicate with you and, if you are directing us to send it to a particular place, the contact/address information.

Inspection and Copies of Protected Health Information

You may inspect and/or copy health information that is within the designated record set, which is information that is used to make decisions about your care. California law requires that requests for copies be made in writing and we ask that requests for inspection of your health information also be made in writing. Please send your request to the person listed below.

We can refuse to provide some of the information you ask to inspect or ask to be copied if the information:

• Includes psychotherapy notes.
• Includes the identity of a person who provided information if it was obtained under a promise of confidentiality.
• Is subject to the Clinical Laboratory Improvements Amendments of 1988.
• Has been compiled in anticipation of litigation.

We can refuse to provide access to or copies of some information for other reasons, provided that we provide a review of our decision on your request. Another licensed health care provider who was not involved in the prior decision to deny access will make any such review. California law requires that we are ready to provide copies or a narrative within 15 days of your request. We will inform you of when the records are ready or if we believe access should be limited. If we deny access, we will inform you in writing. HIPAA permits us to charge a reasonable cost based fee. The California Medical Board has set limits on fees for copies of medical records that under some circumstances may be lower than the charges permitted by HIPAA. In any event, the lower of the fee permitted by HIPAA or the fee permitted by the California Medical Board will be charged.

Amendment of Medical Information

You may request an amendment of your medical information in the designated record set. Any such request must be made in writing to the person listed below. We will respond within 60 days of your request. We may refuse to allow an amendment if the information:

• Wasn’t created by this practice or the physicians here in this practice.
• Is not part of the Designated Record Set?
• Is not available for inspection because of an appropriate denial.
• If the information is accurate and complete.

Even if we refuse to allow an amendment you are permitted to include a patient statement about the information at issue in your medical record. If we refuse to allow an amendment we will inform you in writing. If we approve the amendment, we will inform you in writing, allow the amendment to be made and notify others who received the information.

Accounting of Certain Disclosures

The HIPAA privacy regulations permit you to request, and us to provide, an accounting of disclosures that are other than for treatment, payment, health care operations, or made via an authorization signed by you or your representative. Please submit any request for an accounting to the person listed below. Your first accounting of disclosures (within a 12 month period) will be free. For additional requests within that period we are permitted to charge for the cost of providing the list. If there is a charge we will notify you and you may choose to withdraw or modify your request before any costs are incurred.

Appointment Reminders, Treatment Alternatives, and Other Health-related Benefits

We may contact you by telephone, mail, and/or e-mail to provide appointment reminders, information about treatment alternatives, or other health-related benefits and services that may be of interest to you.

Complaints

If you are concerned that your privacy rights have been violated, you may contact the person listed below. You may also send a written complaint to the United States Department of Health and Human Services. We will not retaliate against you for filing a complaint with the government or us. The contact information for the United States Department of Health and Human Services is:

U.S. Department of Health and Human Services HIPAA Complaint7500 Security Blvd., C5-24- 04Baltimore, MD 21244

Our Promise to You

We are required by law and regulation to protect the privacy of your medical information, to provide you with this notice of our privacy practices with respect to protected health information, and to abide by the terms of the notice of privacy practices in effect.

Questions and Contact Person for Requests

If you have any questions or want to make a request pursuant to the rights described above, please contact us anytime

This notice is effective on the following date: January 1, 2019

We may change our policies and this notice at any time and have those revised policies apply to all the protected health information we maintain. If or when we change our notice, we will post the new notice in the office where it can be seen.

Acknowledgement of Review of Notice of Privacy Practices

I have reviewed this office’s Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document.

You acknowledge that you are the owner of the phone numbers (whether associated with a mobile, cell or landline) and email addresses that you provide to us. If you are not the owner, you represent that you are authorized by the respective owner(s) to authorize the use of those phone numbers and email addresses as described below, on the owner’s behalf. You authorize us and any third party, such as our independent contractors, business associates, agents and/or affiliates, who we may authorize, to:

1. Call you at any of the numbers that you provide to us, using an automatic telephone dialing system and/or using a recorded message upon being answered, or another similar method such as an artificial or pre-recorded voice;
2. Text messages to you at any of the numbers that you provide to us; and/or
3. Send email communications to you at any of the email addresses that you provide us; for any of the following purpose: confirming appointments, providing registration or clinical instructions, communicating about post-service follow up, telemarketing, billing, advertisements, advising you of special offers, events and services, communicating about your account, insurance and payments, and collecting debts that you owe to us. You do not have to give us permission to call, text or email you. Giving us permission to call, text, or email you is not required in order to receive services, to purchase any property or goods. You have the right to opt out of these types of communications.

Consent to Recieve Text Message Appointment Reminders

By signing below, I authorize BASS Medical Group and its affiliates to contact me by automated SMS text message for appointment reminders.

I know that I am under no obligation to authorize BASS Medical Group or its affiliates to send me text messages. I may opt-out of receiving these communications at any time by calling the Service Desk @ (877) 607-6484, or by responding STOP to 622622. Please allow 2-3 business days for processing.

I understand that text messaging is not a secure format of communication. There is some risk that individually identifiable health information or other sensitive or confidential information contained in such text may be misdirected, disclosed to or intercepted by unauthorized third parties. Information included in text messages may include your first name, date/time of appointments, name of physician, and physician phone number, or other pertinent information.

By signing below, I indicate I am the primary user for the mobile phone number listed above, I accept the risk explained above and consent to receive text messages via automated technology from BASS Medical Group and its affiliates to the phone number that I have provided.

I, the responsible party, certify that the above information is true and correct to the best of my knowledge.
I understand that I am financially responsible for all charges regardless of delays in insurance payment or denial of insurance coverage.
It is my responsibility to understand and have personally verified if my insurance is contracted with this practice and/or the doctor I am seeing.
I hereby authorize BASS Medical Group to apply for benefits and receive payments directly on my behalf for covered services rendered. They may also disclose any or all parts of my clinical record to any insurance company covering services for the purpose of satisfying charges billed.
I further agree to pay all collection costs, attorney fees and any other collection costs that may be incurred in the attempt to collect outstanding patient responsibility amounts.
I also understand, that if any insurance payments are sent directly to me, it is my responsibility to send
these monies directly to BASS Medical Group. immediately upon receipt.
I, the patient or the patient’s representative, understand that all medical doctors at BASS Medical Group are licensed and regulated by the Medical Board of California. I can verify this by contacting the Medical Board at (800) 633-2322 or via the internet at their website: www.mbc.ca.gov.

 

The following sets forth the policies of BASS Medical Group. Please review this information and sign where indicated below.

• I understand that it is my responsibility to furnish BASS Medical Group with current, accurate insurance information at the time services are rendered and/or notify us in a timely manner of any changes in coverage, which may affect the payment of services already rendered.

 

• I understand that if I present an insufficient funds check (NSF check) for payment on my account that I will be charged a $25.00 NSF Fee. These amounts must be cleared with our financial office prior to your next appointment.

 

• I understand that a cancellation fee of $50.00 may be billed directly to myself if a 48 hour cancellation notice is not provided to our office. All cancellation fees must be cleared with our financial office prior to your next appointment.

 

• I understand that a surgery cancellation fee of $250.00 may be billed directly to myself if a surgery is cancelled. This fee will also be assessed if cancellation has not been made 7 days prior to scheduled surgery date. This fee must be cleared with our financial office before surgery can be rescheduled.

 

• It is the responsibility of each patient to verify with their insurance if this practice and the physician you are seeing is a contracted provider. BASS and/or its representatives will make every effort to assist you but BASS will not be held accountable for understanding every insurance plan.

 

• I understand that there is a $15.00 fee (per form) to complete disability paperwork associated with my

 

• I understand that the clinic will verify my insurance eligibility for surgery, but until claims are processed deductible amounts and co-insurance amounts prior to surgery cannot be determined. I further understand that a surgery co-pay may be collected upfront and applied to those fees. I further understand that ANY FEES I AM QUOTED ARE ESTIMATED based on 1) anticipated surgery to be performed and 2) current information provided to clinic by my insurance carrier.

 

• I understand that I will be billed for any amounts due by me (co-payments/co-insurance amounts/deductibles) and that I have a financial responsibility to pay these amounts. I understand that I will be provided with at least 2 statements for any balance due after insurance payment. Payment in full is due within 30 days of your first statement unless other arrangements have been made. I further understand that if I have not made payment prior to the third statement being mailed, the third statement will be a final notice and may result in my account being sent to an outside collection service if I still do not fulfill my financial obligations. I also understand that I will be responsible for any collection, interest or legal expenses associated with those collection efforts.

 

• I understand that the clinic may also take a verbal request by me over the phone to make a credit card payment on my account. I give authorization for the clinic to bill my card for the amount specified and acknowledge that verbal requests can only be made by the responsible party since no credit card information is kept on file.

 

 

We are required by law to keep health information confidential. Authorization for the disclosure of health information to someone who is not legally required to keep it private may cause the information to no longer be protected by state and federal confidentiality laws. In accordance with state and federal patient privacy laws, including HIPPA (the Health Insurance Portability and Accountability Act of 1996) this Notice describes how your health information may be used or disclosed and how you, the patient, can get this information. Please review this Notice carefully.

 

PERMITTED USES & DISCLOSURES: The law permits us to use or disclose your health information to the following:

• Another specialist or physician who is involved in your care.

 

• Your insurance company, for the purpose of obtaining payment for our services.

 

• Our staff, for the purpose of entering your information into our computerized system

 

• Other entities during the course of your treatment, in order to obtain authorizations, referral visits, scheduling oftests, etc. Much of this information is sent via fax which is a permitted use allowed by law. We have on file with these sources, verification for the confidentiality of the fax used and its limited access by authorized personnel.

 

• If this practice is sold, your health information will become the property of the new owner.

 

• We may release some or all of your health information when required by law. Except as described above, thispractice will not use or disclose your health information without your prior written authorization.

Federal and state law allows us to use and disclose our patients’ protected health information in order to provide health care services to them, to bill and collect payments for those services, and in connection with our health care operations. We also use a shared Electronic Medical Record that allows both our physicians and staff access to our patients’ health information. The purpose for this access is to expedite the referral of patients within the BASS Medical Group, other

 

providers, and to assist in providing and managing their care in a coordinated way. Information in the Electronic Medical Record can be released outside the BASS Medical Group only with the patient’s express authorization or as otherwise specifically permitted or required by law.

 

PATIENT RIGHTS: The law also establishes patient rights and our responsibility to inform you of those rights. These include:

• You have the right to request in writing any uses or disclosures we make with your health information beyondthe normal uses referenced above.

 

• You have the right to limit the use or restrict the use disclosure of your health information. Our office will followany restrictions notated by you on page 2 of this Form.

 

• You have the right to request in writing to inspect and/or receive a copy of your health information.* Our officemay charge a reasonable fee to cover copying and mailing of these records to you. Some releases of your health information may require the completion and submission of a separate request or form from this one, as our Privacy Officer may determine.

 

• You have the right to request an alternate means or location to receive communications regarding your health information.* Otherwise, such communications will be mailed to the home address in your medical or billing record and/or sent to the alternative address and/or by the alternative means of communication(s) you designate below (E.g., via telephone text or email).

 

• You have the right to request in writing an amendment or change to your health information. Our office may agree or disagree with your written request, but we will be happy to include your statement as part of your
  records. If an agreement to amend or change is acceptable, please be advised that previous documentation is considered a legal document and cannot be deleted or removed. Our office will simply notate the amendment and the reason for it and add it to your records.
  * Conditions and limitations may apply; obtain additional information from our Privacy Officer.

 

• We may use your information to contact you. For example, we may use the U.S. Mail, the telephone, a Text message, or email to remind you of an appointment or call you with information regarding your care. If you are not at home, this information may be left on your answering machine, voicemail, sent via Text, via email, or with the person who answered the phone. In an emergency, we may disclose your health information to a family member or another person designated responsible for your care.

 

• MINORS: We take patient privacy laws very seriously. The State of California limits what type of health information we can share with the parents or legal guardians of minor teenage children between the ages of 12 and 17. Accordingly, we will maintain an exclusive phone number and/or email address for minors in this age range, as they may designate.

 

 

• WHOM I DESIGNATE: Please designate who our offices CAN disclose your health information to, including, but
  not limited to correspondence, test results, prescriptions, medical records, or billing information, who are 18
  years or older, by checking the boxes below and signing below:

We reserve the right to change our privacy practices and the conditions of this notice at any time and without prior notice. In the event of changes, an updated notice will be posted and our office will notify you of the changes in writing. You have the right to file a complaint with the Department of Health and Human Services, 200 Independent Avenue, S.W., Room 509F, Washington, DC 20201. Our office will not retaliate against you for filing a complaint.  However, before filing a complaint, or for more information or assistance regarding your health information privacy, please contact our Privacy Officer at (925) 627-3424.

ACKNOWLEDGEMENT, AUTHORIZATION, & CONSENT

This acknowledges that you have received and read a copy of our Privacy Practices Notice and Consent to the disclosure of your health information to the person(s) or entities you have designated above. This document will remain as part of your medical and billing record.

If person signing is not patient, please provide name and identify the relationship to the patient and in what capacity you/they are signing (E.g., parent, guardian, conservator):

This authorization/consent may be revoked at any time prior to the release of the requested information. The revocation must be in a writing, signed by the patient or their authorized representative, and delivered to BASS at their address referenced below.
Patient’s authorized representative is entitled to receive a copy of this Authorization.
EXPIRATION OF AUTHORIZATION/CONSENT: Unless otherwise revoked, rescinded, revised, updated, or changed by you in a writing signed by you, this Authorization & Consent shall not expire and will last indefinitely.

These questions should be answered by you and your bed partner (or anyone who may have observed you sleeping):

1. Answer them in relation to the last 6 months, unless otherwise specified.
2. A “weekday” should be thought of as any day you routinely work.
3. If you are engaged in shift work or have any type of unusual sleep/wake schedule, “day” and “night” should
   be interpreted as your major wake and sleep periods respectively.

EPWORTH SLEEPINESS SCALE: How sleepy do you feel in the following situations, in contrast to feeling just tired? Even if you haven’t done some of these things recently, try to imagine how sleepy you would feel in these situations.

Use the following scale to choose the most appropriate number for each situation

0= No degree of sleepiness
1= Mild degree of sleepiness
2= Moderate degree of sleepiness
3= Severe degree of sleepiness

TRY TO BE SPECIFIC AND RATE YOUR ANSWERS BASED ON AN AVERAGE NIGHT:

GENERAL MEDICAL QUESTIONNAIRE:

Have you EVER had any of the following?

Review of Systems: If you have had any of the following symptoms in the past 6 months, please list or circle which ones.

Past Surgical History: (i.e. tonsillectomy, adenoidectomy, nasal surgery)

Family History: (Has any of your family members ever had the following conditions?)

NAME ALL MEDICATIONS you are currently taking (prescribed or otherwise): Including herbal, holistic, natural
medications, etc. (use a separate sheet if needtoaddmore)