Name*

First NameLast Name

Sex

Age*

Date of Birth*

Date

Address*

Address

Street Address Line 2

City/State

Zip

Social Security number*

Full number required

Home Phone

Cell Phone*

Work Phone

Email*

example@example.com

Contact Preference

Preferred Language

Martial Status

Race

Ethnicity

Primary Care Doctor

Referring Doctor

How did you hear about us?

Emergency Contact: Name

Phone

Pharmacy Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Pharmacy phone number

INSURANCE INFORMATION

Primary Insurance*

Member #*

Group #*

Subscriber's Name*

Date of Birth*

Date

Claims Phone number

Insurance address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Secondary Insurance (if applicable)

Subscriber's Name

Date of Birth

Date

Member #

Group #

Claims Phone

Guarantor (if other than patient)

Name

Relationship

Date of Birth

Date

Social security number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone

Please enter a valid phone number.

Mobile Phone

Please enter a valid phone number.

I acknowledge the information I provided above is true and correct.

Signature*

Clear

Name*

First NameLast Name

Date*

Date

GENERAL PRACTICE POLICYS

The information provided in this document explains what you can expect as a patient of Texas Sleep Medicine and outlines your responsibilities. Please familiarize yourself with the entire document. A copy will be provided to you. A member of our staff is available to answer your questions. Thank you for placing your trust and confidence with Texas Sleep Medicine.

Appointments: Please arrive prior to your appointment time. Patients arriving late may be asked to reschedule. You will be asked to confirm your demographic and insurance information each time you visit. An appointment reminder will be communicated with you 7 days prior to your appointment. Confirming your appointment is required. If you do not confirm your appointment, your appointment is subject to cancellation.

Appointment Cancellations/Reschedules/ No Shows: We understand unexpected things happen. Please be courteous and contact the office 3 business days in advance should you be unable to keep your scheduled appointment. Without prior advance notice to the office you will be charged a $75 fee for missed office visits, $200 fee for missed sleep studies and a $1000 fee for missed multiple sleep latency tests. A pattern of multiple missed appointments is considered being noncompliant with your healthcare and may be cause for dismissal from the practice. Fees are subject to change at anytime.

Financial Responsibility: All applicable fees, deductibles, coinsurance and copays are collected at the time of service. Balances billed to the patient are due within 30 days of the statement date. Past due balances are subject to collection activity and associated fees. A $35 fee will be charged to your account for checks returned by your bank. You, or your guarantor, are financially responsible for all charges relating to healthcare services received. Please contact our insurance coordinator in advance with any questions regarding insurance and billing at 512-440- 5757 option 4.

Insurance Referrals: Most HMO's and some insurance plans require the patient to obtain a referral from their primary care physician to be treated by a specialist. In this instance, Texas Sleep Medicine must receive the referral prior to scheduling an appointment.

Medical Staff: The care you receive will always remain under the direct supervision of Ashwin Gowda, MD, Board Certified in Sleep Medicine. Participating in the care of every patient are nurse practitioners and clinical nurse specialists who have completed advanced graduate level education and training. They work in collaboration with Dr. Gowda to diagnose and treat conditions pertaining to sleep medicine.

Communications: Our staff work closely with the providers managing your care and play an integral role in daily communications with patients. Many questions or concerns can be addressed by communicating directly with them. As an efficient means of communication with the office you will be invited via email to register with the Patient Portal. The portal is a secure way to send and receive responses as well as view test results.

Prescription Refills: Contact your pharmacy for all prescription refills. Your pharmacy will communicate with our office for all required information. Please be aware no refill requests will be completed after hours or over weekends except in case of emergency. Please allow two business days to process a request and five business days if your insurance requires a prior authorization. You will be charged $40 in advance for staff obtaining a prior authorization.

Additional Services: Occasionally some administrative fees will occur that are not covered by insurance. These services include but are not limited to medical records copy, depositions, completing forms, no show fees, returned check fees and medical prior authorization. You will be charged for these services should they be necessary.

Medical Compliance: A relationship of mutual respect is the basis for a proper plan of care. Patients who become noncompliant with their prescribed treatment plan may be subject to dismissal from Texas Sleep Medicine.

I acknowledge having read General Practice Polices and understand its meaning and purpose.

Patient Signature / Printed Name*

Clear

Print Name*

First NameLast Name

Date*

Date

STATEMENT OF CONSENTS

Provide Treatment: I authorize Texas Sleep Medicine to provide me treatment as necessary, and such treatment will be mutually agreed upon. You will be auto-enrolled in a compliance monitoring service as part of your treatment if CPAP is prescribed. I authorize my insurance benefits to be paid directly to Texas Sleep Medicine. I acknowledge my financial responsibility for payment of services to me including any non-covered or denied services by my insurance.

Initials*

Release of Information: I have reviewed Texas Sleep Medicine's Notice of Privacy which explains how my medical information will be used and disclosed. I understand I am entitled to receive a copy of this document. I authorize the release of information to my insurance concerning my medical condition and for the purpose of claims processing. I also authorize the release of medical information to my referring physician and / or primary care physician. This information will include diagnosis, treatment plans and services provided.

I authorize the release of information to the following individuals until revoked by me in writing:

Name 1

Relationship

Phone

Name 2

Relationship

Phone

Initials*

Photo: During registration I may have a photo taken and attached to my chart as a means of greater identification. I understand if I have my photo taken it will be used solely for that purpose

Initials*

Communication: I understand the need for Texas Sleep Medicine to contact me for multiple reasons including appointments, treatment, follow up and billing issues. I wish not to restrict communication in all usual and customary manners. I have provided all acceptable modes of communication and contact information. I will keep this updated should any of the information change.

I acknowledge the practice has requested I register with the patient portal as a means of efficient communication. I understand this is a secure means of electronic communication that requires an email address and password. Also, this may contain personal information relating to my medical care. It is my responsibility to safeguard my password to the portal.

Initials*

I acknowledge having read the statement of consents and understand its meaning and purpose.

Patient Signature *

Clear

Name*

First NameLast Name

Date*

Date

TEXAS SLEEP MEDICINE

please bring your insurance card and ID to your visit.

GENERAL PRACTICE POLICYS

STATEMENT OF CONSENTS