chasedentalsleepcare.com - Sleep NPF 2024

COMPREHENSIVE HEALTH QUESTIONNAIRE
The purpose of this questionnaire is to determine the nature of your health problem. It is very important to be as accurate as possible in answering the questions. Your partner may be able to assist you.
General Information

This information will become part of your medical record and will remain confidential.
Patient Name:

First NameMiddle NameLast Name
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Best way to reach you?
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone:
Please enter a valid phone number.Format: (000) 000-0000.
May we call you at work?
Email:
example@example.com
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age:
Sex:
Height:
Weight:
lbs.
Marital Status:
SSN:
Occupation:
Emergency Contact:
Relationship:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Referring Physician:
Primary Care Physician:
Pulmonologist:
Current Medical Conditions:List current medical conditions for which you are being treated.
Hospitalizations / Surgeries List: List all hospitalizations and surgeries you have had. (Please be thorough and include surgeries to remove your adenoids or tonsils, or hospitalizations for head injury, seizures or heart conditions.)
Current Medical Conditions: List medications you are currently taking. (Please include prescription and non-prescription medications of all types, including sleep and non-sleep related. Also indicate if you are on supplemental oxygen.)
Allergies List:: Please list any allergies we should be aware of:
If none type, 'No Known Drug Allergies'
Upload picture of your insurance cards

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Upload picture of your drivers license

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Informed Consent for the Treatment of Sleep-Related

Breathing Disorders with Oral Appliance Therapy
You have been diagnosed by your physician as requiring treatment for a sleep-related breathing disorder, such as snoring and/ or obstructive sleep apnea (OSA). OSA may pose serious health risks since it disrupts normal sleep patterns and can reduce normal blood oxygen levels. This condition can increase a person’s risk for excessive daytime sleepiness, driving and work-related accidents, high blood pressure, heart disease, stroke, diabetes, obesity, memory and learning problems, and depression.

What is Oral Appliance Therapy?

Oral appliance therapy (OAT) for snoring and/or OSA attempts to assist breathing by keeping the tongue and jaw in a forward position during sleeping hours. OAT has effectively treated many patients. However, there are no guarantees that it will be effective for you. Every patient’s case is different and there are many factors that influence the upper airway during sleep. It is important to recognize that even when the therapy is effective, there may be a period of time before the appliance functions maximally. During this time, you may still experience symptoms related to your sleep-related breathing disorder.

A post-adjustment polysomnogram (sleep study) is necessary to objectively assure effective treatment. This must be obtained from your physician.

Side-Effects and Complications of Oral Appliance Therapy

Published studies show that short-term side effects of oral appliance therapy may include excessive salivation, difficulty swallowing (with appliance in place), sore jaws or teeth, jaw joint pain, dry mouth, gum pain, loosening of teeth, and short-term bite changes. There are also reports of dislodgement of ill-fitting dental restorations. Most of these side effects are minor and resolve quickly on their own or with minor adjustment of the appliance.

Long-term complications include bite changes that may be permanent resulting from tooth movement or jaw joint repositioning. These complications may or may not be fully reversible once oral appliance therapy is discontinued. If not reversible, restorative treatment or orthodontic intervention may be required for which you will be responsible.

Follow-up visits with the provider of your oral appliance are mandatory to ensure proper fit and a healthy condition. If unusual symptoms or discomfort occur that fall outside the scope of this consent, or if pain medication is required to control discomfort, it is recommended that you cease using the appliance until you are evaluated further.

Alternative Treatments for Sleep-Related Breathing Disorders

Other accepted treatments for sleep-related breathing disorders include behavioral modification, continuous positive airway pressure (CPAP) and various surgeries. The risks and benefits of these alternative treatments should be discussed with your healthcare provider.

It is your decision to choose oral appliance therapy to treat your sleep-related breathing disorder and you are aware that it may not be completely effective for you. It is your responsibility to report the occurrence of side effects and to address any questions to this provider’s office. Failure to treat sleep-related breathing disorders may increase the likelihood of significant medical complications.

If you understand the explanation of the proposed treatment, have asked this provider any questions you may have about this form or treatment, and consent to performance of oral appliance therapy, please sign and date this form below. You will receive a copy.
Patient Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Name:

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA

[This form has been approved by the New York State Department of Health]
Patient Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security Number
Patient Address
I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form:

In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that:
1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only ifl place my initials on the appropriate line in Item 9(a). In the event the health information described below includes any of these types of information, and I initial the line on the box in Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item 8.
2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If I experience discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Division of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for protecting my rights.
3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.
4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.
5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal or state law.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7. Name and address of health provider or entity to release this information:
8. Name and address ofperson(s) or category of person to whom this information will be sent:
9(a). Specific information to be released:
Medical Record from   Date  to  Date
Entire Medical Record  , including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records sent to you by other health care providers.
Other:

Include: (Indicate by Initialing)
InitialAlcohol/Drug Treatment
InitialMental Health Information
InitialHIV-Related Information

Authorization to Discuss Health Information
(b)By initialing here     Initial  I authorize    Name of individual health care provider       to discuss my health information with my attorney, or a governmental agency, listed here:   (Attorney/Firm Name or Governmental Agency Name)
10. Reason for release of information:

Other
11. Date or event on which this authorization will expire:
12. If not the patient, name of person signing form:
13. Authority to sign on behalf of patient:
All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a copy of the form.
Signature of patient or representative authorized by law.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
* Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could identify someone as having HIV symptoms or infection and information regarding a person's contacts

Notice of Privacy Practices

Effective January 1, 2026
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:

Questions? Please contact our Privacy Office at the address/ phone number at the end of this notice.

Who Will Follow This Notice:
We provide health care to patients, residents, and clients in partnership with physicians and other professionals and organizations. The information privacy practices in this notice will be followed by:
- Any health care professional that treats you at any of our locations.
- All contracted service partners for sleep and DME services.
- Any healthcare professional authorized to enter information into your chart, including practicing physicians and other credentialed individuals that participate with us in providing care and services.
- Any business associate or partner with whom we share health information.
Our Pledge to You:
We understand that medical information about you is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive in order to provide quality care and to comply with legal requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This notice applies to all of the records of your care that we maintain, whether created by facility staff or your personal doctor. Your personal doctor may have different policies or notices regarding the doctor’s use and disclosure of your medical information created in the doctor’s office.

We Are Required By Law To:
- Keep medical information about you private.
- Give you this notice of our legal duties and privacy practices with respect to medical information about you.
- Follow the terms of the current notice.
Changes To This Notice:
We may change our policies at any time. Changes will apply to medical information we already hold, as well as new information after the change occurs. If there is a significant change in our policies, we will change our notice and post the new version in areas of the facilities generally accessible by patients and their families. You can receive a copy of the current notice at any time. The effective date is listed just below the title. You will be offered a copy of the current notice each time you register for treatment. You will also be asked to acknowledge in writing your receipt of this notice.

How We May Use And Disclose Medical Information About You:
- We may use and disclose medical information about you with your consent or with the consent of others who are legally permitted to consent on your behalf for treatment (e.g., sending medical information about you to a specialist as part of a referral); to obtain payment for treatment (e.g., sending billing information to your insurance company or Medicare); and to support health care operations (e.g., compiling patient data to improve treatment methods.)
- We may use or disclose medical information about you without your prior authorization for several other reasons. Subject to certain requirements, we may give out medical information about you without prior authorization for public health purposes, birth, death, abuse or neglect and domestic reporting, health oversight audits or inspections, qualified research studies, funeral arrangements and organ donation, workers’ compensation purposes, to prevent or lessen a serious and imminent threat to the health or safety of a person or the public, and other emergencies. We also disclose medical information when required by law, such as in response to a request from law enforcement in specific circumstances, e.g., regarding inmates in their custody, or in response to valid judicial or administrative orders.
- We also may contact you for appointment reminders, or to tell you about or recommend possible treatment options, alternatives, health-related benefits or services that may be of interest to you,
- We may disclose medical information about you to a friend or family member who is involved in your medical care or to disaster relief authorities so that your family can be notified of your location and condition.
Other Uses Of Medical Information:
- In any other situation not covered by this notice, we will ask for your written authorization before using or disclosing medical information about you. If you chose to authorize use or disclosure, you can later revoke that authorization by notifying us in writing of your decision.
Your Rights Regarding Medical Information About You:
- In most cases, you or your personal representative have the right to look at or get a copy of medical information that we use to make decisions about your care, when you submit a written request. If you request copies, we may charge a fee for the cost of copying, mailing or other related supplies. If we deny your request to review or obtain a copy, you may submit a written request for a review of that decision.
- If you believe that information in your record is incorrect or if important information is missing, you have the right to request that we amend the records, by submitting a request in writing that provides your reason for requesting the amendment. We could deny your request to amend a record if the information was not created by us; if it is not part of the medical information maintained by us; or if we determine that record is accurate. You may appeal, in writing, a decision by us not to amend a record.
- You have the right to a list of those instances where we have disclosed medical information about you, other than for treatment, payment, health care operations or where you specifically authorized a disclosure, when you submit a written request. The request must state the time period desired for the accounting, which must be less than a 6-year period and starting after your date of service. You may receive the list in paper or electronic form. The first disclosure list request in a 12-month period is free; other requests will be charged according to our cost of producing the list. We will inform you of the cost before you incur any costs.
- If this notice was sent to you electronically, you have the right to a paper copy of this notice.
  You have the right to request that medical information about you be communicated to you in a confidential manner, such as sending mail to an address other than your home, by notifying us in writing of the specific way or location for us to use to communicate with you.
- You may request, in writing, that we not use or disclose medical information about you for treatment, payment or healthcare operations or to persons involved in your care except when specifically authorized by you, when required by law, or in an emergency. We will consider your request but we are not legally required to accept it. We will inform you of our decision on your request.
- All written requests or appeals should be submitted to our Privacy Office listed below:
Complaints:
- If you are concerned that your privacy rights may have been violated, or you disagree with a decision we made about access to your records, you may contact our Privacy Office.
- Finally, you may send a written complaint to the U.S. Department of Health and Human Services Office of Civil Rights. Our Privacy Office can provide you the address.
- Under no circumstance will you be penalized or retaliated against for filing a complaint.

Acknowledgment of Notice of Privacy Practices
The above notice describes how medical information about you may be used and disclosed and how you can get access to information. I have received a copy of this office’s Notice of Privacy Practices.

YOU MAY REFUSE TO SIGN THIS ACKNOWLEDGMENT
Please Print Name
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
OFFICE USE ONLY

We attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices, but acknowledgment could not be obtained because:
- Individual refused to sign
- Communications barriers prohibited obtaining the acknowledgment
- An emergency situation prevented us from obtaining acknowledgment
- Other (Please Specify)___________________________
Medical Records Release Form
Patient’s Name:
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
By Signing this form, I authorize you to release confidential health information about me, by releasing a copy of my medical records, or a summary or narrative of my protected health information, to the physician/person/facility/entity listed:
Patient Signature:
Date signed:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Rows	Never	Slight	Moderate	High
Sitting and Reading.
Watching TV.
Sitting inactive in a public place (e.g. a theater or a meeting).
As a passenger in a car for an hour without a break.
Lying down to rest in the afternoon when circumstances permit.
Sitting and talking to someone.
Sitting quietly after lunch without alcohol.
In a car while stopped for a few minutes in traffic.

Rows	Never	Rarely	Often	Frequent	Always
How often do you rotate shifts?
Does your job require overnight travel?
Do you drink alcohol at 6pm?
Do you drink caffeinated beverages after 6pm?
Do you suffer from a loss of libido?
(Males) Have you experienced difficulties with sexual functions?
(Females) Does your sleep problem vary according to the stage of your menstrual cycle?
(Females) Have you gone through menopause or had a hysterectomy?
Are you able to fall asleep and awaken on a daily, weekly basis according to your desired schedule?
Do you nap during the day or evening?
Do you feel refreshed after a typical night’s sleep?
Do you feel sleepy during the day even when you have slept all night?
Do you feel refreshed after a short nap?
Do you get sleepy while driving?
Have you had an accident or near-accident when driving, due to excessive sleepiness?
Do you fall asleep when you want to stay awake (movies, theater, church, or watching television)?
Are you able to fight off the excessive sleepiness?
Do you have memory or concentration problems?
Do you experience vivid dream-like scenes upon awakening or falling asleep?
When you are angry or laugh, do you ever feel weak, as though you might fall?
Are you ever unable to move or speak upon falling asleep or awakening?
Do you have trouble falling asleep when you go to bed?
When you try to fall asleep does your mind race with thoughts?
When you try to fall asleep do you feel pain?
Does pain ever wake you up, disrupt your sleep or keep you from going back to sleep?
Are you a light sleeper, easily awakened?
Is your sleep disrupted because of your bed partner or others in your household?
Do you snore?
Does your snoring stop for brief periods during sleep?
Does your breathing sometimes stop during sleep?
Is your bed partner disturbed by your snoring?
Do you wake up choking or gasping for breath?
Do you have night sweats?
Do you have heartburn at night?
Do you have a bitter bile taste in the back of your throat when you wake up (not “morning breath”)?
Do you have nasal / sinus congestion at night?
Do you have morning headaches?
Are you a restless sleeper, tossing and turning at night?
Do you have a creeping or crawling sensation in your legs when you lie down to sleep?
Do you experience any type of leg or back pain during the night?

Rows	Right Side	Left Side
Migraine
Headaches
Do you have pain around/behind the eyes?
Pain in jaw
Pain in neck
Pain in shoulder
Ringing sound in ears (tinnitus)
Do you have pain in the ear?
Pain in forehead
Grating sound in joint
Subjective hearing loss
Dizziness (vertigo)

Rows	Yes	No
Upset stomach- nausea
Fullness, pressure
Blockage in ear/congestion

COMPREHENSIVE HEALTH QUESTIONNAIRE

General Information

EPWORTH SLEEPINESS SCALE

HEALTH QUESTIONS

Sleep Health Concerns & Habits

Temporomandibular Joint Disorder (TMJ/TMD) & Pain Concerns

Other Pain Questions

DYSFUNCTION

MISCELLANEOUS AND ASSOCIATED COMPLAINTS AND QUESTIONS

AFFIDAVIT FOR INTOLERANCE OR NON-COMPLIANCE TO CPAP

Informed Consent for the Treatment of Sleep-Related

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA

Notice of Privacy Practices

Acknowledgment of Notice of Privacy Practices

Medical Records Release Form