New Patient Forms - Sleep Apnea

Patient Information

Date of Birth

Sex

Male Female

Primary Phone #

Type of Phone

Home Mobile Work

Email Address

Preferred method(s) of communication:

Phone

Text

Address

Line 2

City

State

ZIP

Marital Status

Single Married Separated Divorced Widowed Other

If "Other" please explain:

Height

Weight

Emergency Contacts

Emergency Contact Person

Relationship to Patient

Primary Phone #

Type of Phone

Home Mobile Work

Email Address

Add Additional Emergency Contact

Financial Information

Who will be financially responsible for you?

Myself Someone Else

If "Someone Else" please fill out the information below:

Full Name

Relationship to Patient

Primary Phone #

Type of Phone

Home Mobile Work

Email Address

Insurance Policy Information

Do you have medical insurance?

Yes No

If "Yes" please enter your policy information below, beginning with your Primary Insurance Policy.

Primary Insurance Policy

Insurance Company

Policy #

Group #

Insurance Co. Phone #

Address

Line 2

City

State

ZIP

Policy Holder's Full Name

Relationship to Patient

Policy Holder's SS#

Date of Birth

Add Additional Insurance Policy Information

Additional Information

Please list your preferred pharmacies in order of preference.

Pharmacy Name

Phone #

Address

Line 2

City

State

ZIP

Add Additional Pharmacy Information

How did you hear about us?

Medical History

Please check all that apply.

Head "Other"

Eyes "Other"

Nose/Sinus "Other"

Urinary "Other"

Cardiovascular "Other"

Respiratory "Other"

Digestive "Other"

Skin "Other"

Musculoskeletal "Other"

Endocrine "Other"

Neurologic "Other"

Psychiatric "Other"

Oncology "Other"

Are you allergic to any medications?

Yes No

If "Yes" please list all of your allergies to medicine(s).

Medicinal Allergy

Add Medication Allergy

Are you currently taking any medications?

Yes No

If "Yes" please list any current medications you are taking.

Medication

Add Additional Medication

Are you pregnant or nursing?

Yes No

Date of last physical exam

Please list your healthcare providers, beginning with your primary care physician.

Healthcare Provider

Add Additional Healthcare Provider

Surgical History

Please check all that apply.

Nasal/Sinus Surgery

Adenoidectomy/Tonsillectomy

Cancer Surgery

Back Surgery

Hysterectomy

Hip Replacement

Spinal/Cervical Fusion

Other

If "Other", please explain.

Dental History

Name of current Dental Provider

Date of last dental exam

Please check all that apply.

Dental Implants

Dentures

Jaw Surgery

Night Guard for teeth grinding

Orthodontic (Braces) Treatment

Wisdom Teeth Extracted

Other

"Other"

Dental work scheduled/in progress:

Major dental work:

Sleep Apnea History

Who is referring you?

Who is your Sleep Doctor?

Have you ever had a sleep study to check for Obstructive Sleep Apnea (OSA)?

Yes

If you answered "Yes" and have had multiple studies, list the most recent one without a CPAP

Where?

When?

Prior/Current treatments

Never had treatment

Tried CPAP, but not using

Tried Oral Appliance, but not using

Surgical Procedures

please list any procedure info below

Currently using CPAP

Currently using a Sleep Appliance

Other

Add Surgical Procedure

What would you like to accomplish with oral appliance therapy?

Dr. Kushner will discuss Oral Appliance therapy in detail with you and will answer your questions. Do you have any specific concerns or questions that are very important to you?

We believe that sleep quality is a very important issue and often requires team approach. We will work closely with your sleep doctor and/or Primary care doctor. Are there any other health/wellness providers that you would like us to share your treatment progress with?

Add Health/Wellness provider

Epworth Sleepiness Scale

This questionnaire was developed to determine the level of daytime sleepiness in individuals. It has become one of the most frequently used methods for determining a person’s average level of daytime sleepiness.

Please rate how likely you are to doze or fall asleep in the following situations by selecting the response that best applies. If you have not done some of these activities recently, select what would most likely happen if you were in that situation.

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

0 = would NEVER doze
1 = SLIGHT CHANCE of dozing
2 = MODERATE CHANCE of dozing
3 = HIGH CHANCE of dozing

It is important that you answer each question as best you can.

Sitting and Reading

0 1 2 3

Watching TV

0 1 2 3

Sitting, inactive in a public place Example: Theater or Meeting

0 1 2 3

As a passenger in a car for an hour without a break

0 1 2 3

Lying down to rest in the afternoon when circumstances permit

0 1 2 3

Sitting and talking to someone

0 1 2 3

Sitting quietly after lunch without alcohol

0 1 2 3

In a car, while stopped for a few minutes in traffic

0 1 2 3

Epworth Sleepiness Score

Please add together the total number from your responses above and enter total here.

Medicare rules state if a patient's Medicare has been billed for a CPAP, BIPAP, or an oral appliance within the last 5 years, the patient may be denied benefits for an oral appliance. Based upon the Same and Similar Medicare guidelines please complete the following:

I request to be treated for my sleep apnea using an oral sleep appliance, (HCPCS E0486) prescribed by my physician and provided by my dentist.

1. My Medicare has been billed for a CPAP or BIPAP Machine in the last 5 years

Yes No

2. The SUPPLIES for my CPAP or BIPAP machine have been billed to my Medicare in the last 5 years

Yes No

3. My Medicare has been billed for an oral appliance within the last 5 years

Yes No

I understand if I answered Yes to the above questions, I am required to obtain from my physician the following:

Medical notes clearly indicating a change in my condition warranting a new piece of equipment.
Why CPAP or BIPAP is no longer sufficient.

By answering No to the above questions, I understand if my Medicare has for CPAP, BIPAP, oral appliance I may be responsible for my new appliance based upon the Same and Similar guidelines laid out by Medicare.

Acknowledgement of Receipt of Statement of Privacy Practices

I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of TMD Sleep Apnea Clinic. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility.

TMD Sleep Apnea Clinic reserves the right to change the privacy practices currently described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed or otherwise transmitted to me.

Additional Disclosure Authorization

In addition to the allowable disclosures described In the Statement of Privacy Practices, I hereby specifically authorize disclosure of my Protected Healthcare Information to the person(s) identified below. (I understand that the default answer is "NO". Without indicating "YES" in answer to each individual question, protected health information (PHI) 'cannot be shared with anyone unless otherwise allowed by HIPAA rules.)

Spouse Only

Yes No

Any Member of my immediate family: (i.e. Spouse, Children, Siblings, etc.)

Yes No

Any Member of my extended family: (i.e. Parents, Grandchildren, etc.)

Yes No

Other

Yes No

Authorization of Release

I authorize the release of a full report of examination findings, diagnosis, treatment program, etc., to any referring or treating health care professional. I additionally authorize the release of any medical information to insurance companies for legal documentation to process claims. I understand that I am responsible for all charges for treatment to me regardless of insurance coverage.

Patient's Full Name

Today's Date

Legal Guardian's Full Name (if patient is a minor)

I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.

Your information will be encrypted.

New Patient Forms - Sleep Apnea

Patient Information

Emergency Contacts

Financial Information

Insurance Policy Information

Additional Information

Medical History

Surgical History

Dental History

Sleep Apnea History

Epworth Sleepiness Scale

Medicare rules state if a patient's Medicare has been billed for a CPAP, BIPAP, or an oral appliance within the last 5 years, the patient may be denied benefits for an oral appliance. Based upon the Same and Similar Medicare guidelines please complete the following:

Acknowledgement of Receipt of Statement of Privacy Practices

Additional Disclosure Authorization

Authorization of Release

Center for TMJ & Sleep Solutions NW