Dallas Sleep - PEDIATRIC NEW PATIENT INFORMATION

PEDIATRIC NEW PATIENT INFORMATION
Full Name:*
Patient Sex:
Birthday:*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status:
E-Mail Address:*
example@example.com
Home Phone #:*
Cell Phone #:
Work Phone (Plus Extension) #:

Pharmacy Name:
Pharmacy Phone #:
Pharmacy Fax #:
Pharmacy Main Cross Streets:
Social Security #:
Drivers License #:
State:
Employer:
Employer Address:

Street Address

Street Address Line 2

CityState

Zip Code
Emergency Contact Phone #:
Emergency Contact:
Relationship to Patient:

GUARANTOR INFORMATION IF DIFFERENT FROM ABOVE
Guarantor Name:
Relationship to Patient:
Marital Status:
Home Phone #:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer:
Employer Phone #:
Employer Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-Mail Address:
example@example.com
Guarantor Social Security #:
Birthday:

MonthDayYear
Date
Sex:

INSURANCE INFORMATION

PRIMARY
Insurance Co Name:*
Employer of Policy Holder:*
Name of Policy Holder:*
Relationship to Patient:*
Insurance Claim Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Claim Phone #:*
Policy Holder Birthdate:*

MonthDayYear
Date
Sex:*
Insurance ID #:*
Group #:*
Effective Date:*

MonthDayYear
Date
Secondary Insurance Co Name:
ASSIGNMENT OF BENEFITS: I hearby assign all medical and/or surgical benefits to which I am entitled including major medical, Medicare, Private Insurance and any other health plan to The Dallas Center for Sleep Disorders. This agreement will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by insurance and I hearby authorize said assignee to release all information necessary to secure payment.
***PAYMENT IS EXPECTED AT THE TIME SERVICES ARE RENDERED***
Signature*

Clear
Date:*

MonthDayYear
Date

FINANCIAL POLICY
Thank you for choosing us as your health care provider. We are committed to your treatment being successful. Please understand that payment of your bills is considered a part of your treatment. The following is a statement of our financial policy, which we require you to read, agree to, and sign prior to any treatment. Dr. Kakar and the providers of Dallas Sleep render only services that, in their professional judgment, are needed to provide quality medical care for you.
PAYMENT IS DUE AT THE TIME OF SERVICE

We accept cash, Discover, American Express, Visa, or Mastercard
REGARDING INSURANCE:

Our office is pleased to assist you in filing claims with your insurance company for reimbursement of your medical expenses with us.
- The patient is responsible to pay any deductible and co-payments prior to or at the time services are rendered.
- It is your responsibility to know if a referral is necessary for your visit.
- Any portion of a billed amount that is labeled “not allowed” or “not covered” will be the patient’s responsibility. This is not the contractual obligation amount the physician will discount due to the practice’s relationship with your insurance plan.
- Our office NEVER guarantees that your insurance will pay, or that they will pay what they quoted our benefits team. We will make every attempt at the beginning of your health care to receive verification of your policy benefits. However, if for some reason your insurance claim is denied, you are responsible for the amount due on your account.
- If your insurance has not processed and paid your claim within 6 months, you will be responsible for the balance on your account.
- Your insurance is a contract between you and the insurance company. We are not party to that contract. While we have an agreement with the Plan to provide services, any questions regarding coverage must be resolved by you with your insurance company.
USUAL AND CUSTOMARY RATES

Our practice is committed to providing the best treatment for our patients, and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s determination of usual and customary.
NSF CHECKS

All returned checks will assess a $30.00 fee. All returned checks not paid in 15 days will be filed with the proper authorities.

Thank you for understanding our financial policy and the necessity of explaining this in writing to our patients. Please let us know if you have any questions or concerns.

I have read, understand, and agree to the provisions of this financial policy.
Signature of patient or responsible party if patient is a minor:*

Clear
Date:*

MonthDayYear
Date

THE DALLAS CENTER FOR SLEEP DISORDERS HIPAA NOTICE OF PRIVACY PRACTICES
This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

This notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment of health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

1. Uses and Disclosures of Protected Health Information

Your protected health infor mation (PHI) may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your healthcare with any related health services. This includes the coordination or management of your health care with a third party. For example, we would disclose your PHI as necessary, to a durable medical equipment company that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment: Your PHI will be used, as needed, to obtain payment for your health care services; For example, obtaining approval for an overnight sleep study may require that your relevant protected health information be disclosed to obtain approval or authorization.

Healthcare Operations: We may use or disclose, as needed, your PHI in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, licensing or conducting or arranging for other business activities. In addition, we may use a sign in sheet at the registration desk where you will be asked o sign your name. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment.

We may use or disclose your PHI in the following situations without your authorization. These situations include, as required by law, public health issues as required by law, communicable diseases, abuse or neglect, FDA requirements, legal proceedings, law enforcements, coroners, criminal activities, military activities and national security, and worker’s compensation. Under the law, we must make disclosures to your and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of section 164.500.

Other permitted and required uses and disclosures will be made only with your consent, authorization or opportunity to object unless required by law.

You may revoke the authorization at any time, in writing, except to the extent that your physician’s practice has taken an action in reliance on the use of disclosure indicated in the authorization.
Acknowledgement of Review of Notice of Privacy Practices

I have reviewed this office’s Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document.
Signature of Patient or Personal Representative:*

Clear
Date:*

MonthDayYear
Date
Name of Personal Representative:
Description of Personal Representative:

NO SHOW AND CANCELLATIONS
Scheduled appointment times are reserved especially for you. If an appointment is missed or cancelled with less than 24 hours notice for office appointments and Sleep Studies, you will be billed:

$100 for new patient appointments

$35 for clinic appointments

$250 for Sleep Study appointments

Please note that calls must be received during our regular business hours. Our hours are Monday – Friday, from 8 am to 5 pm.

Please know that your insurance company does not cover this charge. Repeated “no show” appointments could result in referring you back to your insurance company for reassignment to another specialist.

I understand that the office will make every attempt to place a reminder call for my appointments. However, whether or not a confirmation call is placed, I am still held responsible for remembering my appointment day and time.
Signature:*

Clear
Printed Name of Patient:*
Date:*

MonthDayYear
Date

PAST MEDICAL HISTORY
1 .
2 .
3 .
4 .
PAST SURGICAL HISTORY
1 .
2.
3.
4.
MEDICATIONS (including prescription and over-the-counter)
1 .
2 .
3 .
4 .
ALLERGY HISTORY

(to any medications or substances)
Allergies:*

None KnownYES, to:
1 .
2 .
3.
4.

THE EPWORTH SLEEPINESS SCALE
Full Name:*
Your Age (Years):*
Your Sex:*

MaleFemale
Date:*

MonthDayYear
Date
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. 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
Situation
Sitting and reading:*
Watching TV:*
Sitting, inactive in a public place (i.e. a theater or 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 the car, while stopped for a few minutes in traffic:*
Dallas Sleep

6313 Preston Road, Suite 400 | Plano, Texas 75024
T 972.473.7300 | F 972.473.7750
Should be Empty:

	Yes	No
Loss of Appetite
Sweats:
Fever
Fatigue
Weight Gain
Weight Loss

	Yes	No
Cough
Shortness of Breath
Wheezing
Poor Exercise Tolerance

	Yes	No
Heartburn/Indigestion
Black or Bloody Stools
Diarrhea
Nausea/Vomiting
Jaundice
Abdominal Pain

	Yes	No
Bed Wetting
Frequent Urination
Difficulty Urinating
Blood in Urine

	Yes	No
Sneezing
Runny Nose
Itchy Eyes or Nose
Hives

PEDIATRIC NEW PATIENT INFORMATION

GUARANTOR INFORMATION IF DIFFERENT FROM ABOVE

INSURANCE INFORMATION

PAYMENT IS EXPECTED AT THE TIME SERVICES ARE RENDERED

FINANCIAL POLICY

PAYMENT IS DUE AT THE TIME OF SERVICE

REGARDING INSURANCE:

USUAL AND CUSTOMARY RATES

NSF CHECKS

THE DALLAS CENTER FOR SLEEP DISORDERS HIPAA NOTICE OF PRIVACY PRACTICES

Acknowledgement of Review of Notice of Privacy Practices

MEDICAL INFORMATION RELEASE FORM (HIPAA RELEASE FORM)

Release of Information

Messages

NO SHOW AND CANCELLATIONS

PEDIATRIC NEW PATIENT REGISTRATION & MEDICAL BACKGROUND INFORMATION

PATIENT INFORMATION

SLEEP HISTORY

PAST MEDICAL HISTORY

PAST SURGICAL HISTORY

MEDICATIONS (including prescription and over-the-counter)

ALLERGY HISTORY

SOCIAL HISTORY

Caffeine

FAMILY HISTORY

REVIEW OF SYMPTOMS (ROS)

THE EPWORTH SLEEPINESS SCALE

Situation

	Yes	No
Palpitations
Chest Pain
Daytime Shortness of Breath
Nighttime Shortness of Breath
Ankle Swelling

	Yes	No
Weakness
Seizures
Involuntary Tongue Biting
Passing Out
Dizziness
Headaches
Numbness

	Yes	No
Unexplained Weight Loss
Unusual Bleeding/Bruising
Swollen Lymph Nodes

	Yes	No
Weight Gain
Heat Intolerance
Excessive Thirst
Constipation
Cold Intolerance

	Yes	No
Excess Stress
Memory Loss
Difficulty with Focus, or Concentration
Hallucinations
Nervousness or Anxiety
Depressed Mood

	Yes	No
Stiff/Sore Joints
Muscle Pain
Red or Swollen Joints

	Yes	No
Blurry Vision
Double Vision
Vision Loss

	Yes	No
Hearing Loss
Sore Throat
Sinus Congestion
Hoarseness

	Yes	NO
Unusual Moles
Rash
Dryness

PEDIATRIC NEW PATIENT INFORMATION

GUARANTOR INFORMATION IF DIFFERENT FROM ABOVE

INSURANCE INFORMATION

***PAYMENT IS EXPECTED AT THE TIME SERVICES ARE RENDERED***

FINANCIAL POLICY

PAYMENT IS DUE AT THE TIME OF SERVICE

REGARDING INSURANCE:

USUAL AND CUSTOMARY RATES

NSF CHECKS

THE DALLAS CENTER FOR SLEEP DISORDERS HIPAA NOTICE OF PRIVACY PRACTICES

Acknowledgement of Review of Notice of Privacy Practices

MEDICAL INFORMATION RELEASE FORM (HIPAA RELEASE FORM)

Release of Information

Messages

NO SHOW AND CANCELLATIONS

PEDIATRIC NEW PATIENT REGISTRATION & MEDICAL BACKGROUND INFORMATION

PATIENT INFORMATION

SLEEP HISTORY

PAST MEDICAL HISTORY

PAST SURGICAL HISTORY

MEDICATIONS (including prescription and over-the-counter)

ALLERGY HISTORY

SOCIAL HISTORY

Caffeine

FAMILY HISTORY

REVIEW OF SYMPTOMS (ROS)

THE EPWORTH SLEEPINESS SCALE

Situation

PAYMENT IS EXPECTED AT THE TIME SERVICES ARE RENDERED