Patient Registration/ Information Sheet
Name: _______________________________________________________________________________ Last First Middle
Date of Birth: ____________________________ Social Security Number: ___________________ Street Address: __________________________
Gender: F M Marital Status: ______________
City: _________________ State: ____ Zip: ______ Home Phone: ________________
Ethnicity: ___________________ Work Phone: ________________ Race: ______________________ Cell Phone: _______________ Language: _________________ Employment Status: ____________________________________________________________________ Employer: ________________________________
Street Address: ___________________________ Occupation: _______________________________ City: __________________State: ___ Zip: _______ Emergency Contact: ________________________
Street Address: ___________________________ Home Phone: _____________________________ Work Phone: ______________________________
Relationship: ______________________________ City: __________________State: ___ Zip: _______ Cell Phone: _______________________________ May we email you information from time to time? Yes No
If yes, can you please provide us your email address? _________________________________________ Your information will be used for Sleep Center Orange County purposes only and will not be provided to any other sources without express permission.
Person Responsible for charges: __________________________________________________________ Relationship: _____________________________ Contact Number:___________________________ Address (if different): ______________________ City: _________________State:____ Zip: _______
Primary Insurance: HMO POS/PPO Medicare Cash Other_________
Insurance Company Name: ____________________________
Policy / ID Number: __________________________________ Group Number: __________________ Primary Insurance Subscriber: ________________
Date of Birth: _____________________________ Relationship: ______________________________ Secondary Insurance: HMO POS/PPO Medicare Cash Other________ Insurance Company Name: ________________
Policy / ID Number: _______________________ Group Number: __________________________
Whom may we thank for referring you to our Practice? ________________________________________ Treating Physicians: ____________________________________________________________________
I hereby assign my insurance benefits to be made directly to my physician and any assisting physicians, for services rendered. I hereby attest that the above insurance information is accurate and that I am an eligible member and understand that I am responsible for knowing my benefits / coverage and tests ordered by my physician may NOT be covered. I will be financially responsible for all charges that are not covered by my insurance company. I also hereby authorize the release of all information to other physicians and insurance carriers upon request for the purpose of payment for the medical services and further treatment of care by another physician. I further agree that a photocopy of this agreement shall be valid as the original. Payment is due at the time services are rendered. All charges are the direct responsibility of the patient. Sleep Center Orange County, Inc. cannot render service on the assumption that the charges will be paid by the Insurance Company. Insurance is an agreement between you and your insurance company. If Sleep Center Orange County, Inc. has problem collecting payment from you, we will also add attorney’s fees, collection agency costs and any related fees to your bill. I hereby acknowledge that I have read, understand and agree to hereby give consent for treatment.
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Sleep Clinic
New Patient Questionnaire
Name:
Date of Birth: ____________
Date:
Reason for your visit to the sleep clinic:
Please give this questionnaire to your healthcare provider who will clarify and review this
questionnaire with you in detail.
Current complaint: (please check answer) Yes No Unsure Loud or habitual snoring
Stop breathing while asleep Excessive daytime sleepiness
Sleepiness interfering with daily activities Decreased energy/fatigue during the day Unrefreshing sleep
Morning headaches
Frequent awakenings from sleep Choking or “snorting” while asleep Short of breath during sleep Sweating while asleep
Difficulty breathing on your back Daytime naps / dozing
Sleep walk Sleep talk
Act out dreams (kick, punch, scream etc.) Hallucinations prior to falling asleep Feel paralyzed just before falling asleep Kick / move your legs while asleep Sudden muscle weakness when emotional Grind teeth while asleep
Leg restlessness (crawling, aching feeling) Difficulty falling asleep
Difficulty staying asleep Use sleeping medication
Anxiety / racing thoughts prior to sleep Sour or acid taste in mouth at night Body pain at night
Weight changes over last two years Nasal Congestion at night
Bed time: Out of bed time:
Other complaint / concerns
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Recently have you experienced? Yes No
Double vision or vision changes Headache
Sinus congestion or pain Chest pain
Irregular heart beats Shortness of breath at rest Cough
Do you currently have? Yes No
Feelings of sadness Feelings of guilt
Loss of interest in usual hobbies Decreased concentration Change in appetite Change in sleeping pattern Feelings of moving slow Blood in your stool
Bed wetting
Heat or cold intolerance
Abdominal pain Diarrhea Nausea/ vomiting
Loss of consciousness (not sleep) Heart burn
Shortness of breath with exertion Memory Loss
Past Medical History: Yes No
Sleep apnea High blood pressure Seizure or Epilepsy Diabetes
Stroke / TIA
Heart disease/irregular heart beat Asthma/COPD/Lung disease Parkinson’s disease Depression/Anxiety/Mood disorder Iron deficiency Cancer Any surgeries Other:
Current Medications:
Yes No Medication allergies
Social History: Yes No
Married Children Bed partner
Daily coffee cola or caffeine use Alcohol use
Cigarette/pipe/cigar smoking Recreational drugs Occupation:
Family History: Yes No
Sleep apnea Stroke Diabetes Heart disease Other sleep disorder
The above information is true to the best of my knowledge.
Signature: _______________________
Last Name First Name
Cancellation / “No Show” Policy
Most people are considerate in providing us with advance notice to allow us to make the time available for other patients who need appointments. This policy is in place due to the
unfortunate fact that we continue to encounter some patients who cancel at the last minute. We are making every effort to be “up front” and clear about our cancellation policy so there is no misunderstanding. Please keep in mind that unlike a lot of other medical offices, we do not double book appointment slots. We reserve a time block for each individual patient, a time that is set aside only for you and your care.
Cancellations, rescheduling, and not showing for follow up appointments require a minimum of 24 hours’ “Business Day” notice to cancel appointments. If you do not give us advance notice to cancel or reschedule your appointment (new or follow-up), a $25.00 fee will be charged. Because a large block of time is reserved for you, cancellation or rescheduling of Sleep Study appointments requires a minimum of two business days (48 hours) notice IN ADVANCE to avoid a fee. A $300.00 fee will be charged for any sleep study cancelled less than the required notice. A voice mail message left after business hours is not acceptable. Our regular business hours are Monday-Friday, 9:00AM-5:00PM.
We certainly understand that situations arise and patients need to change appointments. We are happy to work with you to reschedule appointments. All we ask is that you give us enough advance notice. We sincerely appreciate your consideration and cooperation.
By signing below, I acknowledge that I have read and accept the above cancellation policy.
___________________________________ Signature
___________________________________ Printed Name
___________________________________ Date
___________________________________ Relationship to patient
4980 Barranca Parkway, Suite 170, Irvine, CA 92604 Tel: (949) 679-5510 Fax: (949) 679-1080
I understand that I am being evaluated for a sleep disorder that can cause sleepiness during the daytime, as well as, in the evening hours.
I understand the safety risks of sleepiness, especially when I am driving or doing anything that requires my attention and alertness. I understand that if I drive while sleepy, I may cause injury to myself and others.
I will refrain from driving when sleepy and otherwise adjust my activities until my sleepiness has resolved. I know that if I have any other questions about the safety risks of my condition, I can call the clinic and discuss them.
By signing below, I agree to the above statements.
Patient Name ____________________________________ DOB ____________________
Last Name First Name
Consent Form for Medical Information Disclosures
Sleep Center Orange County, Inc.
• Wesley Elon Fleming, M.D., and employees / independent contractors who provide
healthcare services
• Armaghan Azad, M.D., MPH. and employees / independent contractors who provide
healthcare services
In connection with the medical services that I am receiving from the above-‐named physician/provider, I hereby authorize the above-‐named physician/provider to disclose any or all information concerning my medical condition and treatment, including copies of applicable hospital and medical records to:
A. Any third party payor covering the medical services of the patient
B. Other health care professionals and institution involved in the delivery of health care to the
patient
C. The proponent of any legally sufficient subpoena, or in response to a court order
D. Employees and agents of the practice, to the degree necessary to facilitate the provision of
health care services and payment for such services
E. Pharmacies
F. Other parties as otherwise required by the law.
In each case, the practice shall take reasonable steps to ensure that only the minimum necessary information is disclosed in accordance with the above.
I am consenting to receive my medical information by the following communication method-‐ Please check all that apply:
Telephone conversation Telephone message on my home answering machine.
Home Phone Number: ____________________________________________________________ Telephone message on my office voicemail. Work Phone Number: ________________________ Leave telephone message with: (name of individuals who are authorized to receive you medical information by phone)
______________________________________________________________________________ Telephone message on my cell phone. Mobile Phone Number: ________________________ I consent to have my medical information discussed with:
Please check all that apply and include name: Spouse:
__________________________
Children: _________________________
Parents: _________________________ Other: ___________________________ I consent to have my medical information shared with my physicians:
Please check and fill in all that apply:
Primary Physician: ________________ Other M.D.: ______________________
Other M.D.: ______________________ Other M.D.: ______________________ This consent is valid from the date executed until revoked in writing by the patient.
Signature: _____________________________________________ Date: ___________________ If person other than patient is signing, please print full name and indicate relationship below.
Last Name First Name
HIPAA Privacy Notice
In accordance with the Health Insurance Portability and Accountability Act of 1996, patient of this practice are entitled to the greatest degree of privacy possible. This office will strive to ensure that patient
information is used only for authorized purposes as agreed to by the patient. Patients are advised that they have a right to review their medical files upon reasonable notice to the practice during normal business hours, and to make comments to the same. Patients have the right to direct the methods of communication of their medical information and to specify the individuals to whom that wish their medical information released to, in addition to those indicated on the “consent for medical information disclosure” form.
Practice Policy and Procedures
• Before any records are released, staff will review to ensure that the release has been authorized
by the patient or is otherwise permitted.
• Before any records are released, staff will review to ensure that only the information necessary
has been released.
• Only members of the staff shall have access to medical records. Staff members shall have
access limited to portions of the records directly related to their duties (for example, the secretary shall have access to the pharmacy records for the purpose of refilling prescriptions).
• At the close of the business each day, all computers containing medical information shall be
secured and logged off of or placed in the physician’s office.
• Each patient chart shall include records of all releases of information, including the date, to whom
the information was sent and the material included.
• Oral PHI (Protected Health Information) should not be communicated in general patient areas. All
discussion regarding patient care shall be conducted either in the patient’s examination room or in the physician’s private office. In emergencies, other arrangements may be made on a case by case basis.
• Oral PHI should not involve unnecessary parties. Discussions concerning patients should never
be made in another patient’s examination room.
• Common area conversations concerning patients are to be avoided. • Out-of-office conversations regarding PHI are forbidden.
• Parents and Minors
Only the parent or legal guardian of a child has a right to access records.
Exceptions include:
• State law pre-emption (e.g., applicable state law concerning pregnancy or sexually
transmitted diseases) • Court order • Potential abuse or neglect • With parent or guardian consent
Receipt of Privacy Notice
By signing below, I confirm that I have received and read the privacy notice given to me in accordance to HIPPA.
Signature: _____________________________________________ Date: ___________________
If person other than patient is signing, please print full name and indicate relationship below.
Print Full Name: __________________________________ Relationship: ___________________
Any question regarding this privacy notice should be directed to this practice’s HIPPA compliance officer, Ms. Ellen Miller. Phone: (949) 679-5510 Ext. 4
