Hawaii Sleep Life Med Intake Form

Sleep Life Med Intake Form
Thank you for your interest in a sleep consultation with Sleep Life Med (office of Dr. Valerie Cacho and Dr. Jessalyn Wong). To better assist you please complete the following intake form.

This form is to be completed by the patient or someone who has legal medical decision making capacity for the patient (Please also complete our Permitted Communications form).

If you have Quest Integration or a HMSA HMO plan, your insurance requires an authorization prior to scheduling. Please contact your primary care physician for the authorization/referral.
Patient Name*

First NameLast Name
Guardian Name - if the patient is younger than the age of 18, or name of person completing this form if not the patient

First NameLast Name
Patient Date of Birth

MonthDayYear
Date
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient's Best Phone Number*

Area CodePhone Number
Patient's Email*
example@example.com
Preferred method of communication
By choosing text message you acknowledge that message and data rates may apply. Text messages are unencrypted and there may be a security risk with use. We recommend using the free HIPPA protected Spruce App as a secure form of communication. Please use this link to join: https://spruce.care/sleeplifemed or scan the QR code below.
Please briefly state your reason for a sleep consultation *
If you have a CPAP machine, please take a photo of the serial number (SN) on the back and upload it here.

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If you are on a CPAP machine, which company gives you CPAP supplies?

Pacific Island MedicalApriaAloha RespiratoryCoastal Medical SupplyOther
ID and Medical Insurance Card

Please be careful that uploaded photos are clear.
Government issued ID card (eg. Driver's license, HI State ID, Military ID, etc)*

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Medicare ID number (if applicable)
Primary medical insurance card (front)*

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Primary medical insurance card (back)*

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Secondary medical insurance card (front)

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If applicable Cancelof
Secondary medical insurance card (back)

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If applicable Cancelof
Tertiary medical insurance card (front)

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If applicable Cancelof
Tertiary medical insurance card (back)

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If applicable Cancelof
Policies
FINANCIAL POLICIES:

I understand that I am financially responsible for all charges whether covered or not by my medical insurance carrier. It is my responsibility to find out what services are covered.

Copayments are due at the time of service and further appointments will NOT be scheduled if there is a balance on your account.

A late fee of $5 per month will be applied to outstanding bills over 60 days.

Hawaii residents are responsible for paying the general excise tax.

In the event you are unable to pay your bill within 60 days of the invoice a payment plan can be arranged by contacting us at 808-500-7077 or billing@sleeplifemed.com.

If we have been unable to obtain payment in full or maintain scheduled payment arrangements from you after 120 days of repeated attempts, the account will be sent to a collection agency and you may be discharged from the practice.
NO SHOW POLICY:

Your appointment time has been reserved for you. We understand that emergencies arise and reserve the right to charge a no show or cancellation fee $50 for physician appointments and $100 for home sleep apnea tests WITHOUT 24 hours of advanced notice.

LATE POLICY:

Please let us know if you are running late. If you are unavailable within 8 minutes your scheduled time you will be considered a NO SHOW and the above fee will be charged.
Patient or Guardian Signature *

Clear
Should be Empty:

Sleep Life Med Intake Form

ID and Medical Insurance Card

Policies