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INTAKE PACKET

Please complete prior to your first appointment.
Nevin Arora MD, Diplomate, Am. Board of Sleep Medicine

Kristen LaMarca, PhD, Clinical Psychologist, Diplomate in Behavioral Sleep Medicine

Phone: (760) 650-2290

Fax: (760) 400-3026

www.luciditysleeppsych.com
Office Policies & Consent to Treatment
The following has been prepared in order to facilitate our work together. Please read this document carefully, and communicate any concerns so they may be addressed immediately.

Confidentiality

The law, professional ethics, and common sense require that all information disclosed within sessions is confidential and may not be revealed to anyone without your written permission. There are, however, some exceptions to the rule where disclosure is required by law: where there is a reasonable suspicion of child, dependent or elder, abuse or neglect; where a patient presents a danger to self, to others, to property, or is gravely disabled, or when required by a court of law. Insurance Providers (when applicable) and other third-party payers may be given information related to services rendered. More details are available upon request of our Notice of Privacy Practices.

Patient Portal: Registration and Online Scheduling

All scheduling is completed online. To schedule, patients are required to use the calendar of the online portal “Patient Ally”, which can be accessed through our website or at www.PatientAlly.com, in lieu of contacting us by phone. Your cooperation leaves us more available to tend to more important aspects of your care. If necessary, you may request appointments by calling (760) 650- 2290 ext. 2001 during business hours.

When registering with the portal, you will receive an email from Patient Ally with a link to the portal. Once you create an account, complete any paperwork under the “Documents tab”. Call us if you have difficulty using Patient Ally.

Follow-up appointments will be confirmed within 1 business day in the portal. Request to reschedule or cancel appointments through the messaging feature of the portal.

Be aware that both Dr. Arora and Dr. LaMarca practice in more than one office location, which is specified in their calendars on Patient Ally. You are responsible for ensuring you are scheduling in the correct location. For your convenience, you may receive optional appointment reminders through our automated system via text, email, or phone call. You are responsible for also marking your appointment times on your personal calendar, however, as the automated reminder system may not be reliable. Please use Patient Ally to keep your information up to date. Send us a message to update your home address, phone number, insurance, and emergency contact information as needed.

Contact Procedures

Phone: For non-emergency matters, contact us by phone at (760) 650-2290. We typically respond within 1-2 business days during normal business hours. Messages left after 5 pm on Fridays will be returned at the beginning of the next week. If there is limited unscheduled telephone consultation of an urgent matter with our doctors between normal sessions, and it is 10 minutes or less, then there will be no charge. However, please bring any concerns related to your treatment to your scheduled appointments.

Portal: Please use the portal to request appointments or message us regarding routine communications.

Email/Text/Social Media: We do not accept communication outside of our phone or patient portal procedures under any circumstance. Contact by social media platforms is discouraged. You may use the portal to message staff or exchange documents regarding routine matters. Please reserve issues of a clinical nature for your face-to-face sessions with your providers.

Emergency procedures: In the case of an emergency, call 9-1-1 or go to the nearest emergency room.

Payment for Services

Payments for services are due at the time the service is rendered or a charge is incurred. Our fees are periodically raised with reasonable advance notice. Please notify us if any problem arises during the course of our work together regarding your ability to make timely payments. If you have not remit payment for outstanding balances or set up a fee payment plan within 90 days of charges, your account will be sent, with reasonable notice to you, to a collection agency. You may request a receipt or detailed statement of charges or summary of your payments at any time.

Your bank statement may include a charge that states, LUCIDITY SP. If you mistakenly initiate an unauthorized chargeback request, you will be charged the fee again, plus any fees acquired for the error, plus an additional $25 administrative fee. You then have 10 business days to re-submit payment for that service. Otherwise a late payment fee of $25 for each unpaid charge will be incurred.

By initialing below and signing this form, I, the patient (or the patient’s representative), acknowledge that payment is due at the time a service is rendered or a charge is incurred. I acknowledge these charges may include fees for missed appointments, late cancellations, or late payment fees.
Initials*
By initialing below and signing this form, I, the patient (or the patient’s representative), acknowledge that if I do not submit payment within 10 business days of receiving an invoice, I will incur an additional $25 fee for late payment.
Initials*
Insurance Reimbursement

If you are using insurance, you must determine the details of your coverage (e.g. deductible, copay, etc.) prior to your visit. Patients who carry insurance with which we are not contracted should remember that professional services are rendered and charged to the patient and not to the insurance company. If you choose to use your out-of- network benefits this means that we will be paid in full, by you, at the time of services rendered. Upon request only, we can supply you with a statement to submit to your insurance company for reimbursement to you, the patient. The only exception to this means of claiming your out of network benefits is if we have agreed to other arrangements for billing your insurance. Remember, we are not in a position to guarantee payment from your insurance company, and you are responsible for costs not covered.

Cancellation Policy

Since the scheduling of an appointment involves the reservation of time held specifically for you, a minimum of 24 business hours notice is required to cancel an appointment (If your appointment is on a Monday, you have until Friday at 6:00pm to cancel). If you fail to cancel in advance of 24 business hours prior to your appointment, you may be billed the entire cost of your missed appointment. In the event that a late cancellation is due to circumstances, which we both define as an emergency, a fee may not be charged. However, if you fail to inform us you will miss your appointment (no-show/no-call) even in the case of an emergency, you will still incur a late cancellation fee unless you inform us that extreme circumstances prevented you from contacting us to cancel it.

If you are unable to make your appointment, please cancel online as soon as possible to allow us to accommodate our schedules. You may also call (760) 650-2290 to cancel your appointment during normal business hours or leave a voicemail.

By initialing below and signing this form, I, the patient (or the patient’s representative) acknowledge that failure to provide notice of at least 24 business hours in advance for reasons that are not an emergency will result in a charge for the full cost of the missed appointment. If I am unable to make an appointment due to an emergency, I acknowledge that I must also contact the office prior to the appointment to cancel in order to avoid a late cancellation fee, unless there are extreme circumstances preventing me from doing so. I acknowledge that I have read and agree with the cancellation policy as outlined above.
Initials*
Records

We use a secure, encrypted electronic health records (EHR) system, Office Ally, to keep records of our sessions and submit insurance claims. You have the right to receive a summary of your records at any time. If you request the release of your information to other agencies or person(s), you will need to sign a written release of information form (these must be renewed at least once per year). You will be informed at the time of your request whether or not it is believed that releasing that information to that agency or person(s) might be harmful to you in any way. If a third party makes a request for your records and we have your permission to do so, we may offer a summary of your record of treatment, versus detailed consultation notes. Requests for paper copies of records, instead of a summary, will incur a cost of $0.25/page plus any mailing or clerical costs. You may also incur a fee to compensate for any time required to review records prior to their release prorated at the clinician’s full hourly rate rounded up to the nearest 15 minutes. If you request paperwork to be completed for you or a written letter, the cost incurred will be at the clinician’s usual hourly rate rounded up the nearest 15 minutes.

Length of Treatment

The length of time of your treatment will vary depending upon a number of factors, and you will evaluate this with your provider on an ongoing basis together. You have a right to discontinue our work at any time and your only obligation at the point of termination is that of a financial nature for balances not yet paid in full. Also, please note that all patients of Dr. LaMarca are required to be seen at least once every 30 days, unless otherwise agreed upon, in order to remain active under her care. If you are not seen within 30 days, and you and Dr. LaMarca have not clearly agreed to keep your case open, your case will be closed and you will be provided with referrals, if desired. If your case is closed, you will need to complete the intake process again in order to re-establish your care.
YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THE ABOVE AND AGREE TO ABIDE BY THESE CONDITIONS:

Clear
Patient Name (or legal guardian)*

First NameLast Name
Date and Time

Patient Information
Date of Birth*

MonthDayYear
Date
Name*

First NameMiddle NameLast NameSuffix
If you do not have a mobile or home number, enter: 000-000-0000
Mobile Number*

Area CodePhone Number
Home Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com. We will use your email to link you with the Patient Portal.
Marital Status*
Employment Status*
How were you referred to us?*
(e.g. your doctor, insurance, web search, etc.)
Primary Care Physician*
Primary Care Physician Phone Number

Area CodePhone Number
Name of Emergency Contact*

First NameLast Name
Relationship to Emergency Contact*
Emergency Contact Phone Number*

Area CodePhone Number
Insurance Information
PRIMARY INSURANCE
Primary Insurance
ID #
Group Number
Insurance Phone Number

Area CodePhone Number
Patient's relationship to insured
Insured's Name
Insured's Date Of Birth

MonthDayYear
Date
Insured's Employer
SECONDARY INSURANCE
Secondary Insurance
ID #
Group Number
Insurance Phone Number

Area CodePhone Number
Patient's relationship to insured
Insured's Name
Insured's Date Of Birth

MonthDayYear
Date

Epworth Sleepiness Scale
How likely are you to doze off or fall asleep in the following situations, incontrast to just feeling tired? This refers to your usual way of life in recenttimes. Even if you have not done some of these things recently try to workout how they would have affected you. Use the following scale to choose themost appropriate number for each situation.

0 = would never dose
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing

Situation*

	Chance of Dozing
Sitting and Reading
Watching TV
Sitting, in active in a public place (e.g. theater, or meeting)
As a passenger in a car without a break
Lying down to rest in the afternoon when circumstances permit
Sitting, talking with someone
Sitting quietly after a lunch without alcohol
In a car, while stopped a few minutes in traffic

Click submit below to send your forms to Lucidity Sleep Psychiatry.
Should be Empty:

	Sleep apnea	Narcolepsy	Insomnia	Restless Leg Syndrome	Depression	Anxiety	Bipolar Disorder	Other psychiatric disorder (list in comments)	Unknown/Not applicable
Father
Mother
Sister
Brother
Grandparents
Children

	0 = Disagree	1	2	3	4	5	6	7 = Agree
My motivation is lower when I am fatigued.
Exercise brings on my fatigue.
I am easily fatigued
Fatigue interferes with my physical functioning.
Fatigue causes frequent problems for me.
My fatigue prevents sustained physical functioning.
Fatigue interferes with carrying out certain duties and responsibilities.
Fatigue is among my three most disabling symptoms. Fatigue interferes with my work, family, or social life.

	None	Mild	Moderate	Severe	Very Severe
Difficulty falling asleep
Difficulty staying asleep
Problems waking too early

	Not at all	A little	Somewhat	Much	Very Much
How NOTICEABLE to others do you think your sleep problem is in terms of impairing your quality of life?
How WORRIED / DISTRESSED are you about your current sleep problem?
What extent do you consider your sleep problem to INTERFERE with your daily functioning (e.g. daytime fatigue, mood, ability to function at work/daily chores, concentration, memory, mood, etc.) CURRENTLY?

INTAKE PACKET

Office Policies & Consent to Treatment

Patient Information

Background Questionnaire

Epworth Sleepiness Scale

Fatigue Severity Scale (FSS) of Sleep Disorders

Insomnia Severity Index