lungsleepwellness.com - New Patient Paperwork

Patient Demographics
Name

First NameMILast Name
Sex

MaleFemale
Date of birth

MonthDayYear
Date
Social Security #
Marital Status
Mailing Address

Mailing Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell phone
Please enter a valid phone number.
Preferred Contact Method

Work phoneHome phoneCell phone
Employer
Emergency Contact Name
Phone Number
Please enter a valid phone number.
How did you hear about us?

Friend/FamilyInternetSignMagazine
Email Address
example@example.com
If you are a referral then by what doctor?
Phone Number
Please enter a valid phone number.
Who is your primary care physician?
Phone Number
Please enter a valid phone number.
Insurance Information
Primary Insurance
Policy #
Subscriber Name
DOB

MonthDayYear
Date
Relationship
Secondary Insurance
Policy #
Subscriber Name
DOB

MonthDayYear
Date
Relationship
Billing Information
Name of responsible party(If other than self)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to patient
DOB

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
I authorize release of any medical information to process this claim.
Signature

Clear
Date

MonthDayYear
Date
I authorize payment of medical benefits to my physician for service provided.
Signature

Clear
Date

MonthDayYear
Date

OFFICE FINANCIAL POLICY
Our goal is to provide and maintain a good physician-patient relationship. Letting you know in advance of our office policy allows for a good flow of communication and enables us to achieve our goal Please read this carefully and If you have any questions, please do not hesitate to ask a member of our staff.

1. On arrival, please sign in at the front desk and present your current insurance card. IF THE INSURANCE COMPANY THAT YOU DESIGNATE 15 INCORRECT, YOU WILL BE RESPONSIBLE FOR PAYMENT OF THE VISIT AND TO SUBMIT THE CHARGES TO THE CORRECT PLAN.

2. According to your insurance plan, you are responsible for any and all co-payments, deductibles, and co-insurances.

3. It is your responsibility to understand your benefit plan. It is your responsibility to know if a written referral or authorization's required to see specialists, if preauthorization is required prior to a procedure, and what services are covered.

4. If our physicians do not participate in your insurance plan, payment in full is expected from you at the time of your office visit. For scheduled appointments, prior balances must be paid prior to the visit, you will be asked to re-schedule.

5. If you have no Insurance, payment for an office visit must paid at the time of the visit or you will be asked to reschedule.

6. Co-payments are due at the time of service or you will be asked to reschedule.

7. Statements are sent out at the end of the month. Your remittance is due within 10 business days of your receipt of your bill.

8. If previous arrangements have not been made with our finance office, we request that you notify our office 72 hours before your scheduled appointment time to discuss your account with our finance person, or you will be asked to reschedule.

9. We require a 24-hour notice for canceling any appointments. There is a$35.00 fee for office visits and a $50.00 fee for PFT visits if they are not canceled OR if a 24-hour notice is not given. There is a $250.00 fee for sleep studies if not canceled within 72-hours (3 business days)

10. A $45.00 fee will be charged for any checks returned for insufficient funds, in addition to any bank fees incurred.

11. Na all services provided by our office are covered by every insurance plan. Any service determined to not be covered by your plan will be your responsibility.

I have read and understand this office financial policy and agree to comply and accept the responsibility for any payment that becomes due as outlined previously.
Patient Name(s)

Notice of Privacy Practices Receipt

I acknowledge that I was provided with the Notice of Privacy Practices at the Lung and

Sleep Wellness Center.
Patient Name
Patient's Signature

Clear
Date

MonthDayYear
Date
Patient's DOB

MonthDayYear
Date
Personal Representative of the Patient (if applicable)
Print Name of Personal Representative:
Describe Personal Representative Relationship (parent, guardian, etc):
Signature of Personal Representative:

Clear
Date

MonthDayYear
Date
Signature of Practice Employee

Clear
Date

MonthDayYear
Date
HIPPA Privacy:

I agree to allow Lung and Sleep Wellness Center, P.C. to leave a message: (Please check all that apply)
on my answering machine. Only for me
I agree to allow Lung and Sleep Wellness Center, P.C. to discuss my medical care with:

	Name	Relationship to you
1
2
3

Patient's Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

	SELF	FAMILY	RELATIONSHIP
DIABETES
CANCER
ASTHMA
COPD
HEART DISEASE
SHORTNESS OF BREATH
HIGH BLOOD PRESSURE
EMPHYSEMA
PNEUMONIA
TUBERCULOSIS
POSITIVE PPD
BRONCHITIS

	Yes	No
Are you on any oxygen at home(nocturnal/continuous/exertional)?
Do you have any history of blood clots?
Have you been exposed to tuberculosis?
Do you have a history of COPD?
Do you have a history of asthma?
Have you had any recent hospitalizations?
Do you have a prior history of lung cancer?
Do you have a prior history of lung surgery?
Do you have a prior history of pneumonia?

	Yes	No
Do you have a prior history of sleep apnea?
Are you using a CPAP or Bipap machine?
Do you have nonrestorative sleep?
Do you have any excessive daytime sleepiness?
Do you snore?
Is the snoring disruptive?
Do you have any witnessed apneas? (has someone seen you stop breathing In your sleep)
Do you ever wake up choking or gasping for air?
Do you have disturbed sleep?
Do you wake up with headaches?
Does your snoring wake you from your sleep?
Do you have any history of restless leg syndrome?
Do you notice any leg movements In your sleep?
Do you act out your dreams?
Do you grind your teeth?
Do you sleep walk?
Do you have nightmares?
Do you have sleep paralysis?
Do you have any hallucinations?
Do you have cataplexy?
Do you work 2nd or 3rd shift?
Do you have any unexplained arousals of sleep?
Have you had a prior sleep study?
Do you have any family members with sleep apnea?
Have you gained any weight recently?

	No chance	Slight chance	Moderate chance	High chance
Sitting and reading
Watching tv
Sitting Inactive Ina public place
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sifting and talking to someone
Sitting quietly after lunch without alcohol
In a car, while stopped for a few minutes in traffic

Patient Demographics

Insurance Information

Billing Information

Patient Past Medical History

Social History

Pulmonary History

Sleep Assessment

Epworth Sleep Questionnaire

Review of System

OFFICE FINANCIAL POLICY

Personal Representative of the Patient (if applicable)