New Patient Paperwork

Patient Information Form

Last Name

First Name

Status

S M W D

Address

Home Phone

Cell Phone

Work

DOB

Age

Sex

Social Security #

Email Address

Ethnicity

Hispanic or Latino

Non-Hispanic or Latino

Other

Decline

Race

American Indian or Alaska Native

Asian

Black or African American

Native Islander or another Pacific Native

White

Other

Out Of Sate Address

City ,State ,Zip

Home Phone

Emergency Contact Name

Phone Number

Relationship to the Patient

PLEASE GIVE THE FRONT DESK YOUR INSURANCE CARDS / PHOTO ID TO COPY FOR YOUR FILE

Referring Physician

Primary Physician

Primary Insurance

Policy #

Insured’s Name

Relationship to Patient

Secondary Insurance

Policy #

ASSIGNMENT OF BENEFITS: (Allows us to file for your insurance) I hereby assign all medical, to include major medical benefits which I am entitled including Medicare and private insurance and any other health plans to: Sleep Manatee. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is valid as the original. I understand that I am financially responsible for all charges whether paid by said insurance. I hereby authorize said assignee to release all information necessary to secure payment. I authorize Sleep Manatee to download my medication history and RX benefits into my account from an RX clearinghouse.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signed

Date

PREVIOUS SURGERIES/DATES

Add Surgery

YOUR CURRENT MEDICINES, INCLUDING DOSAGE AND FREQUENCY

WHAT DRUG OR ENVIRONMENTAL ALLERGIES DO YOU HAVE?

SOCIAL HISTORY: (Please Check All That Apply)

Tobacco Use

Never Quit Cigarettes Pipe Cigars Chewing Tobacco

Quit: When?

Cigarette: Pack/Day

How many years?

Alcohol Use

None Socially Daily

Drug Use

None Marijuana Amphetamines Other

Caffeine Use

None Occasional Daily

Exercise

None 1 - 2x week 3 - 4x week 5 - 7x week

FAMILY HISTORY: Does any direct relative have:

Asthma

Emphysema

Allergic condition

Diabetes

Lung cancer

High blood pressure

Sleep disorders

Heart problem before age 60

Pharmacy

Phone

Address

Fax

Print:

Date:

Sign:

No Show/Late Cancellation Policy

We strive to provide excellent medical care to all our patients. To do so effectively and efficiently, we have an appointment cancellation policy that applies to new and existing patients of the practice.

We understand that situations arise in which you must cancel your appointment. It is, therefore, requested that if you must cancel your appointment, give our office at least 24-hour’s notice for the appointment and 48- hours’ notice for testing. This will allow us to offer that time to another patient on our waitlist.

To remain consistent with our mission, we have instituted the following policy.

A “No-Show,” “No-Call,” or missed appointment without proper 24-hour 48-hour notification may be assessed a fee.

First missed appointment – You will receive a phone call informing you of your missed appointment with the opportunity to reschedule.
Second missed appointment - Any established patient who fails to show or cancels/reschedules an appointment with no 24-48-hour notice will be charged a $50.00 fee.
Third missed appointment - If a third, No Show or cancellation/reschedule with no 24–48-hour notice will be charged a $50.00 fee.
Fourth missed appointment - You will be notified of your fourth missed appointment and may be subject to dismissal from the practice at the physician's discretion.

This fee is NOT billable to your medical insurance.
If you are 15 or more minutes late, the appointment may be canceled and rescheduled.
As a courtesy, we make reminder calls for appointments one or two days in advance. Please note that if a reminder call or message is not received, the cancellation policy remains in effect.

Follow-up appointment: $50

New Patient Sleep/Weight Consultation: $100

Sleep Study: $250

Sleep Study and MSLT: $500

Home Sleep Test: $100

Financial Responsibility

I understand that all applicable copayments and deductibles are due at the time of service. I agree to be financially responsible and pay in full for all charges not covered by my insurance company. I authorize my insurance benefits to be paid directly to Florida Sleep Specialist/Discover Health for services rendered. I authorize Florida Sleep Specialists/Discover Health representatives to release pertinent medical information to my insurance company when requested or to facilitate payment of a claim.

This signature will act as a lifetime authorization for Medicare.

I have read and understood the above Financial Policy and agree to meet all financial obligations.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Name (Please Print)

Patient Signature

Date of Birth

Today’s Date

(If other than the patient)

HIPPA Disclosure Agreement & Disclosure Information

Do we have permission to leave the following on your voicemail?

*Appointment Information

Yes No

*Medical Information

Yes No

*Billing Information

Yes No

*Contact you at work

Yes No

Other than my physicians, I authorize the following person(s) to receive information regarding my medical condition, appointments, and billing:

I would like to receive information/sign up for the Patient online Healthcare Portal:

Yes No

I understand that the person or entity receiving authorized information is not a health plan or health care provider covered by federal privacy regulations, the authorized information may be disclosed by the recipient and may no longer be protected by federal or state law.

I understand that I may revoke this (HIPPA) authorization and that my refusal to sign in no way affects my treatment, payment, enrollment in a health plan or eligibility for benefits.

I hereby acknowledge that I received Sleep Manatee’s Notice of Privacy Practices.

Name of Patient

Patient Signature

Date

Records Release

Name

DOB

Date

I hereby authorize use or disclosure of protected health information about me as described below for the purpose of continuity of care:

Past Sleep Studies

Office Notes

X-ray

Labs

CT Scans

Other

If other, please specify.

Facility/Physician Name

I understand this authorization may be revoked by me at any time except to the extent the information has already released.

Signature

Weight Management History

Name

Date

Purpose of visit: Why are you seeking this visit? (for example, I am seeking help to lose weight because of weight related complications, inability to lose weight by other means, desire for professional guidance to lose weight in a healthy manner).

When did your weight become a problem (year/age of onset)?

What were the circumstances at that time?

(For example: following childbirth, new job, a particular life stress)

Have you dieted to lose weight?

Yes No

Are you currently dieting?

Yes No

What type of eating plan works well for you?

(low carb, vegetarian, balanced reduced calorie, low fat, Paleo, meal replacements)

Do you have any religious or personal food restrictions, including food allergies/ sensitivities)?

(kosher, vegan, lacto-ovo vegetarian, gluten free, lactose intolerance):

Have you lost more than 20 pounds through dieting at any time in your life? If so, list when, weight lost, method, and long-term result:

For example: 1989, lost 60# by diet and exercise, kept off for 3 years.

Have you ever taken weight loss prescription medication? If so please list when, and what was the effect, and any side effects.

Have you had weight loss surgery? If so, what procedure, and when. If you have not had surgery, but have contemplated surgery, please describe:

Did you have trouble with your weight as a child? As a teen?:

Is there any history of physical, sexual, or emotional abuse?

Have you ever been diagnosed with an eating disorder?

On a scale of 0-10, how do you rate your desire to make changes in your weight and health? (0= I don’t want to make change, 10= I am 100% motivated to make changes).

On a scale of 0-10, how to you rate your readiness to make changes at this time: (0= not at this time, 10= I am 100% ready to do what it takes).

Do you ever eat in excess, beyond what you know is healthy, and feel compelled to do so or have difficulty stopping?

Do you do so in secret?

Do you feel guilty or remorse later?

On a scale of 1-10, please indicate to degree to which each of the following applies to you:

Hunger is a strong motivator of my eating habits

Once I start eating, I have difficulty stopping

I cannot resist temptation to eat certain foods

I have strong cravings for certain foods

I cannot have certain foods in my home/environment

I give in easily to temptation to eat

When in social environments, I have trouble adhering to my plan

Family events, holidays, and traditions are trigger times

I eat out of boredom

I eat due to stress, or to help calm anxiety

I eat out of fear of getting hungry

I have trouble limiting my intake if I haven’t eaten in several hours

I have increased craving in the evening

I can tell the difference between true hunger vs. want to eat

I often eat even though I am not hungry

Are you frustrated with yourself that you cannot control your weight?

If appropriately recommended for you, do you have any reservations about weight loss medication?

What is your weight loss goal?

Sleep quality (Skip this section if you we are treating you for sleep disorders).

What is your typical bedtime?

What is your typical wake time?

How long does it take to fall asleep?

How many times do you awaken in the night?

Is your sleep refreshing?

Do you snore?

Have you been told you stop breathing in your sleep?

Do you kick or move in your sleep?

Have you had routine bloodwork in the last 6 months? If so, can we request these results?

Do you currently exercise? If so, how many days per week, and for how long? (4x/week walking 1 hour):

Signature

Date

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