2940 Mallory Circle, Suite 204 - Celebration, FL 34747 4553 Pleasant Hill Road – Kissimmee, FL 34759 717 East Michigan Street – Orlando, FL 32806 700 SR 60 East – Lake Wale, FL 33853 Last Name First Name Middle Name Date of Birth Sex: Male Female Marital Status Social Security # - - Race Ethnicity Home address City State Zip Code County Home Phone ( ) Cell ( ) Work ( ) Email Address @ Employment: Full Time Part Time Unemployed Retired Date of Retirement Employer Occupation Primary Care Physician Tel. Who may we thank for referring you to our office? **If you have any records that pertain to your visit at another physician’s office, please have it faxed over prior to your appointment.** Primary Insured Information (if it is not the patient). If you are also financially responsible for all charges please check here. ___ _ _ _ Patient Spouse Father/Mother Other Sex Last Name First Name Middle Name #SS - - Date of Birth Home #( ) Cell ( ) Home address City Zip Code Employed: Full Time Part Time Unemployed Retired Date of Retirement Primary Insurance Secondary Policy # Group # Policy # Group # Emergency Contact (Spouse/Father/Mother or Guardian if the patient is a minor) Name Relation to patient Home # ( _) Cell ( ) Work ( ) PLEASE PROVIDE YOUR INSURANCE CARD AND DRIVER LICENSE TO THE RECEPTIONIST ALONG WITH YOUR COMPLETED FORMS. PLEASE KNOW THAT CO PAYMENTS AND OR DEDUCTIBLES MUST BE PAID FOR AT THE TIME OF YOUR VISIT. IF YOU ARE A MEMBER OF AN HMO IT IS YOUR RESPONSIBILITY TO BRING YOUR REFERRAL FORM TO YOUR VISIT. Signature _Date
11
Embed
Last Name First Name Middle Name - floridalungdoctors.com...2940 Mallory Circle, Suite 204 - Celebration, FL 34747 4553 Pleasant Hill Road – Kissimmee, FL 34759 717 East Michigan
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
2940 Mallory Circle, Suite 204 - Celebration, FL 34747
4553 Pleasant Hill Road – Kissimmee, FL 34759
717 East Michigan Street – Orlando, FL 32806
700 SR 60 East – Lake Wale, FL 33853
Last Name First Name Middle Name
Date of Birth Sex: Male Female Marital Status
Social Security # - - Race Ethnicity
Home address City
State Zip Code County
Home Phone ( ) Cell ( ) Work ( )
Email Address @
Employment: Full Time Part Time Unemployed Retired Date of Retirement
Employer Occupation
Primary Care Physician Tel.
Who may we thank for referring you to our office?
**If you have any records that pertain to your visit at another physician’s office, please have it faxed over prior to your appointment.**
Primary Insured Information (if it is not the patient). If you are also financially responsible for all charges please check here. ___ _ _ _
Patient Spouse Father/Mother Other Sex
Last Name First Name Middle Name
#SS - - Date of Birth Home #( ) Cell ( )
Home address City Zip Code
Employed: Full Time Part Time Unemployed Retired Date of Retirement
Primary Insurance Secondary
Policy # Group # Policy # Group #
Emergency Contact (Spouse/Father/Mother or Guardian if the patient is a minor)
Name
Relation to patient
Home # ( _)
Cell ( )
Work ( )
PLEASE PROVIDE YOUR INSURANCE CARD AND DRIVER LICENSE TO THE RECEPTIONIST ALONG WITH YOUR COMPLETED
FORMS. PLEASE KNOW THAT CO PAYMENTS AND OR DEDUCTIBLES MUST BE PAID FOR AT THE TIME OF YOUR VISIT. IF YOU
ARE A MEMBER OF AN HMO IT IS YOUR RESPONSIBILITY TO BRING YOUR REFERRAL FORM TO YOUR VISIT.
Snoring Sleepy During Day Restless Sleep Difficulty Sleeping
Heartburn Diarrhea Constipation Blood in Stool Hemorrhoids Loss of Appetite
Family History: Have any members of your family ever had the following? (Please check)
DISEASE RELATIONSHIP TO YOU
Diabetes
Lung Cancer
Cancer
High Blood Pressure
Emphysema
Asthma
Kidney Disease
Medication Allergies: Food Allergies:
Pharmacy Name: Phone Number:
Current Medications:
Name Strength How often
Patient Signature Today’s Date
1
Name:
Age:
Date:
Sex M F Height: Weight: BMI:
Please circle your answer:
What time do you usually go to bed on weekdays? 8 PM - 9 PM - 10 PM - 11 PM - 12 AM - 1 AM – 2 AM
How long after getting in bed do you decide to fall asleep?
How long does it take you to fall asleep?
How many hours of sleep do you get on an average night?
INSTRUCTIONS: Please circle the number following each statement that best describes how often you have had any of these
experiences. Unless otherwise noted, the statements refer to what has been happening to you during the past six (6) months.
Circling number “1” after a statement means that you have never had that experience, whereas circling number “5” means
that you almost always have that experience.
ANSWER KEY: 1 = NEVER 2 = RARELY 3 = SOMETIMES 4 = USUALLY 5 = ALWAYS
Part I:
2940 Mallory Circle, Suite 204 - Celebration, FL 34747
4553 Pleasant Hill Road – Kissimmee, FL 34759
717 East Michigan Street – Orlando, FL 32806
700 SR 60 East – Lake Wale, FL 33853
Sleep Questionnaire
I have difficulty falling asleep 1 2 3 4 5 When I awaken during the night I am unable to fall asleep 1 2 3 4 5
At bedtime I am afraid of not being able to fall asleep 1 2 3 4 5
I sleep better when sleeping away from my home 1 2 3 4 5
Thoughts race through my mind when I am trying to go to sleep 1 2 3 4 5
I use alcohol to help me get to sleep 1 2 3 4 5
I use medications to help me get to sleep 1 2 3 4 5
My sleep is disturbed because of pain 1 2 3 4 5
I am anxious or depressed 1 2 3 4 5
I have been told that I snore 1 2 3 4 5
I have been told that my snoring can be heard in other rooms of the house 1 2 3 4 5 I suddenly wake up gasping or choking 1 2 3 4 5 I have been told I stop breathing at times during my sleep 1 2 3 4 5 I have headaches when I wake up in the morning 1 2 3 4 5 At times during the day I struggle to stay awake 1 2 3 4 5 I have trouble at work or school because of sleepiness 1 2 3 4 5
I have fallen asleep during the day involuntarily 1 2 3 4 5 At times during the day I am so tired I find myself doing things that make no sense 1 2 3 4 5
I have been told I kick my leg when I sleep 1 2 3 4 5
My sleep is disturbed by aching or crawling sensations in my legs 1 2 3 4 5
I get out of bed to walk and stretch my legs because of discomfort 1 2 3 4 5
When awakening or falling asleep, I have been awake but felt paralyzed or unable to move 1 2 3 4 5
When awakening or falling asleep, I have experienced vivid dreamlike visions or heard 1 2 3 4 5
I have sudden attacks of muscle weakness when laughing, crying or otherwise very emotional 1 2 3 4 5
I sleep walk at times 1 2 3 4 5 I wake up screaming, confused or violent at times 1 2 3 4 5
The information contained herein is for informational purposes only and is provided on an “as is” basis. WVMI, Quality Insights of Delaware, and their employees make no representation concerning the suitability or accuracy of this information for any purpose. Neither WVMI, Quality Insights of Delaware, nor any of their employees makes any warranty, express or implied, including warranties of merchantability and fitness for a particular purpose, or assumes any legal liability or responsibility for the accuracy completeness, or usefulness of any information, apparatus, product or process disclosed, or represents that its use would not infringe privately owned rights and shall not be liable for any damages whatsoever arising from the use of or reliance on any information contained herein.
Acknowledgment of Receipt of Notice of Privacy Practices I acknowledge that I have received and understand Florida Lung, Asthma & Sleep Specialists, P.A.’s Notice of Privacy Practices containing a description of the uses and disclosure of my health information. I further understand that Florida Lung, Asthma & Sleep Specialist, P.A. may update its Notice of Privacy Practices at any time and that I may receive an updated copy of Florida Lung, Asthma & Sleep Specialist, P.A. Notice of Privacy Practices by submitting a request in writing for a current copy of Florida Lung, Asthma & Sleep Specialist, P.A. may update its Notice of Privacy Practices.
Printed Patient Name
Patient Signature Date
If completed by patient’s personal representative, please print name and sign below.
Printed Patient Personal Representative Name Relationship to Patient
Patient Personal Representative Signature Date
For Florida Lung, Asthma & Sleep Specialists, P.A. Official Use Only
Complete this form if unable to obtain signature of patient or patient’s personal representative.
Florida Lung, Asthma & Sleep Specialist, P.A. made a good faith effort to obtain patient’s written acknowledgement of the Notice of Privacy Practices but was unable to do so for the reasons documented below:
Patient or patient’s personal representative refused to sign Patient or patient’s personal representative unable to sign Other
Employee Name (Printed)
Employee Signature Date
2940 Mallory Circle, Suite 204 - Celebration, FL 34747
4553 Pleasant Hill Road – Kissimmee, FL 34759
717 East Michigan Street – Orlando, FL 32806
700 SR 60 East – Lake Wale, FL 33853
HIPAA Information and Consent Form
The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a “friendly” version. A more complete text is available in the office.
What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov
We have adopted the following policies:
1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination rooms, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI, and other documents or information.
2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S. mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes in office policy and new technology that you might find valuable or informative, insurance items, and items pertaining to your clinical care such as: laboratory and pathology results, diagnostic results, among others.
3. You understand and agree to inspections of the office and review of documents which may include PHI by Government agencies or insurance payers in normal performance duties.
4. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.
5. We agree to provide patient with access to their medical records in accordance with state and federal laws.
6. We may change, add, delete, or modify any of these provisions to better serve the needs of both the patient and the practice.
7. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.
8. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.
9. I authorize the following people to be able receive information regarding my medical condition:
Relationship
Relationship
Relationship
I, , do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.