Fountain Valley Regional Sleep Center Lab #1

PATIENT INFORMATION

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Name*

First NameLast Name

Address*

Street Address

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CityState / Province

Postal / Zip CodeCountry

Phone #*

Area CodePhone Number

Cell #*

Area CodePhone Number

Driver's License #*

Gender*

MaleFemale

Marital Status*

SingleMarried

Date of Birth*

MonthDayYear

Age*

E-mail*

Employer

Work/Contact#::

Emergency Contact Name:

Emergency Contact Relationship:

Emergency Contact Phone Number:

Area CodePhone Number

SPOUSE INFORMATION

Spouse's Name:

First NameLast Name

Spouse's Employer:

Spouse's Work #:

Area CodePhone Number

Spouse's Date of Birth

MonthDayYear

INSURANCE INFORMATION

Primary Insurance:*

Name of Insured:*

Insured ID#:*

Group #:

Plan #:

Secondary Insurance:

Secondary Insurance ID#:

Group #:

Plan #:

Referred by:

Referred by contact #:

Medication List*

Medications Allergic to:

Date*

Date

Signature*

NOTICE OF PRIVACY PRACTICES (HIPAA)

The Health Insurance Portability & Accountability Act of 1996 (HIPAA), a federal program, requires we maintain the privacy of your health information and all medical records used or disclosed by us in any form. HIPAA provides penalties for entities misusing personal health information. HIPAA dictates we may use and disclose your medical records only for the following purposes. Treatment - provide, coordinate, or manage health care and related services by one or more health care providers. Payment - obtain reimbursement for services, confirm coverage, bill or collect charges, and for utilization review. Health care operations - business aspects of running the practice, i.e.: conduct quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. We may also create and distribute health information by removing all references to the patient’s identity. We may contact you to schedule appointments or provide information about benefits and services that may be of interest to you. If we cannot reach you personally we may leave a message on your answering device (answering machine, cell phone, etc.) or another person who answers your phone. Other uses and disclosures will be made only with your written authorization, which you may revoke in writing. We will honor and abide by that written request, except for information previously released on your authorization. You have the following rights with respect to your protected health information, which you may request in writing.

1. The right to request restriction on certain uses and disclosures of protected health information, including disclosures to family members, other relatives, close personal friends, or any other person identifies by you. We will honor the restriction until you withdraw it in writing. In certain emergency circumstances we may not be required to honor the restriction.

2. The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.

3. The right to inspect and copy your protected health information.

4. The right to amend your protected health information.

5. The right to receive an account of disclosures of protected health information. This Notice of Privacy Practices is effective August 1, 2004. We reserve the right to change the terms of our Privacy Practices and to make the new terms effective for all protected health information we maintain. We will post and you may request a written copy of a revised Notice from this office. If you feel your privacy protections have been violated, you have the right to file a written complaint with our office, or with the agency noted below. We will not retaliate against you for filing a complaint.

For more information: The U.S. Department of Health & human Services (202) 619-0257 Office of Civil Rights (877) 696-6775 Toll Free 200 Independence Avenue, S.W. Washington, D.C. 20201

NOTICE OF PRIVACY PRACTICES (HIPAA)

The Health Insurance Portability & Accountability Act of 1996 (HIPAA), a federal program, requires we maintain the privacy of your health information and all medical records used or disclosed by us in any form. HIPAA provides penalties for entities misusing personal health information. HIPAA dictates we may use and disclose your medical records only for the following purposes. Treatment - provide, coordinate, or manage health care and related services by one or more health care providers. Payment - obtain reimbursement for services, confirm coverage, bill or collect charges, and for utilization review. Health care operations - business aspects of running the practice, i.e.: conduct quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. We may also create and distribute health information by removing all references to the patient’s identity. We may contact you to schedule appointments or provide information about benefits and services that may be of interest to you. If we cannot reach you personally we may leave a message on your answering device (answering machine, cell phone, etc.) or another person who answers your phone. Other uses and disclosures will be made only with your written authorization, which you may revoke in writing. We will honor and abide by that written request, except for information previously released on your authorization. You have the following rights with respect to your protected health information, which you may request in writing. 1. The right to request restriction on certain uses and disclosures of protected health information, including disclosures to family members, other relatives, close personal friends, or any other person identifies by you. We will honor the restriction until you withdraw it in writing. In certain emergency circumstances we may not be required to honor the restriction. 2. The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations. 3. The right to inspect and copy your protected health information. 4. The right to amend your protected health information. 5. The right to receive an account of disclosures of protected health information. This Notice of Privacy Practices is effective August 1, 2004. We reserve the right to change the terms of our Privacy Practices and to make the new terms effective for all protected health information we maintain. We will post and you may request a written copy of a revised Notice from this office. If you feel your privacy protections have been violated, you have the right to file a written complaint with our office, or with the agency noted below. We will not retaliate against you for filing a complaint. For more information: The U.S. Department of Health & human Services (202) 619-0257 Office of Civil Rights (877) 696-6775 Toll Free 200 Independence Avenue, S.W. Washington, D.C. 20201

Date*

Date

SLEEP STUDY INFORMED CONSENT FORM

SLEEP STUDY INFORMED CONSENT FORM

A sleep study or polysomnogram (PSG) is an overnight test during which several physiologic functions are monitored. These include brain activity, eye movements, muscle tone, heart rhythm, airflow from the nose and mouth, breathing effort, blood oxygen levels and leg movements. Attaching small gold electrodes to the surface of the scalp or skin monitors most of these functions. The skin is not punctured. Six (6) electrodes attached to the scalp monitor brain activity. The electrodes are attached with paste which is easily removed in a warm shower. The patient’s brain activity is monitored to determine if, during the course of the sleep study, the patient is asleep or awake and to determine the patient’s then current sleep stage(s). The patient’s eye movements are measured by placing electrodes near the outer edge of each eye. Eye movements are measured to determine if the patient is in the stage of REM (rapid eye movement) sleep where dreaming occurs. Muscle tone is measured by placing two (2) electrodes—both are placed on the patient’s chin. Muscle tone is measured to help determine if the patient is in REM sleep as well as identifying bruxism (teeth grinding). Heart rhythm is measured by placing two (2) electrodes on the chest. Airflow from the nose and mouth are measured by a small device called a thermistor beneath the nose. Airflow is measured to determine if the patient is experiencing sleep apnea/hypopnea syndrome. This is a disorder in which there are either pauses in airflow (apnea) or reductions in airflow (hypopnea) during sleep due to obstruction of the upper airway. Breathing effort is measured by placing elastic belts around the chest and abdomen. These electrodes are placed over the pajamas and help to determine the type of breathing problems that are occurring. Blood oxygen level is measured by placing a small device on the finger. This device shines a small red light into the finger and is completely painless. Leg movements are measured by placing two (2) electrodes on each leg. Leg movements are measured to determine if the patient has a disorder in which the legs twitch repeatedly throughout the night which is called periodic limb movement disorder (PLMD) which can also be disruptive to sleep. Each patient bedroom has a television and a comfortable bed. Electrode attachment takes about an hour. Usually three (3) patients undergo sleep studies each night (each patient has a private room). A patient will go to bed with lights out between 9:00 p.m. and 10:00 p.m. Lights on time is usually around 5:00 a.m. After the electrodes are attached, the electrode wires are wrapped into a bundle to prevent tangling. All the wires plug into a small box that is connected to recording equipment in a nearby control room. If the patient needs to visit the restroom during the night, notify a technician. The box can be unplugged by a technician and easily carried into the restroom by the patient. It takes about five (5) minutes to disconnect all the electrodes in the morning. Continuous positive airway pressure (or CPAP) may also be used during the patient’s sleep study. A CPAP machine is a device that delivers room air through a hose and into a mask that is worn over the nose. The nasal mask is kept in place by elastic headgear. The incoming air helps to prevent the upper airway from collapsing, thereby eliminating the breathing pauses that are occurring in sleep apnea syndrome. There are no known side effects (or material risks) associated with the performance of a sleep study. Fountain Valley Regional Sleep Center is required to disclose or report certain medical diagnosis information to local health departments or the Center for Disease Control and prevention. Reportable information includes cases of HIV, tuberculosis, viral meningitis and certain other diseases. I understand that, once the sleep study is commenced, a patient may terminate the sleep study at any time. I AGREE TO UNDERGO THE SLEEP STUDY AS ORDERED BY MY PHYSICIAN

A sleep study or polysomnogram (PSG) is an overnight test during which several physiologic functions are monitored. These include brain activity, eye movements, muscle tone, heart rhythm, airflow from the nose and mouth, breathing effort, blood oxygen levels and leg movements. Attaching small gold electrodes to the surface of the scalp or skin monitors most of these functions. The skin is not punctured. Six (6) electrodes attached to the scalp monitor brain activity. The electrodes are attached with paste which is easily removed in a warm shower. The patient’s brain activity is monitored to determine if, during the course of the sleep study, the patient is asleep or awake and to determine the patient’s then current sleep stage(s). The patient’s eye movements are measured by placing electrodes near the outer edge of each eye. Eye movements are measured to determine if the patient is in the stage of REM (rapid eye movement) sleep where dreaming occurs. Muscle tone is measured by placing two (2) electrodes—both are placed on the patient’s chin. Muscle tone is measured to help determine if the patient is in REM sleep as well as identifying bruxism (teeth grinding). Heart rhythm is measured by placing two (2) electrodes on the chest. Airflow from the nose and mouth are measured by a small device called a thermistor beneath the nose. Airflow is measured to determine if the patient is experiencing sleep apnea/hypopnea syndrome. This is a disorder in which there are either pauses in airflow (apnea) or reductions in airflow (hypopnea) during sleep due to obstruction of the upper airway. Breathing effort is measured by placing elastic belts around the chest and abdomen. These electrodes are placed over the pajamas and help to determine the type of breathing problems that are occurring. Blood oxygen level is measured by placing a small device on the finger. This device shines a small red light into the finger and is completely painless. Leg movements are measured by placing two (2) electrodes on each leg. Leg movements are measured to determine if the patient has a disorder in which the legs twitch repeatedly throughout the night which is called periodic limb movement disorder (PLMD) which can also be disruptive to sleep. Each patient bedroom has a television and a comfortable bed. Electrode attachment takes about an hour. Usually three (3) patients undergo sleep studies each night (each patient has a private room). A patient will go to bed with lights out between 9:00 p.m. and 10:00 p.m. Lights on time is usually around 5:00 a.m. After the electrodes are attached, the electrode wires are wrapped into a bundle to prevent tangling. All the wires plug into a small box that is connected to recording equipment in a nearby control room. If the patient needs to visit the restroom during the night, notify a technician. The box can be unplugged by a technician and easily carried into the restroom by the patient. It takes about five (5) minutes to disconnect all the electrodes in the morning. Continuous positive airway pressure (or CPAP) may also be used during the patient’s sleep study. A CPAP machine is a device that delivers room air through a hose and into a mask that is worn over the nose. The nasal mask is kept in place by elastic headgear. The incoming air helps to prevent the upper airway from collapsing, thereby eliminating the breathing pauses that are occurring in sleep apnea syndrome. There are no known side effects (or material risks) associated with the performance of a sleep study. Fountain Valley Regional Sleep Center is required to disclose or report certain medical diagnosis information to local health departments or the Center for Disease Control and prevention. Reportable information includes cases of HIV, tuberculosis, viral meningitis and certain other diseases. I understand that, once the sleep study is commenced, a patient may terminate the sleep study at any time.

I AGREE TO UNDERGO THE SLEEP STUDY AS ORDERED BY MY PHYSICIAN

Date*

Date

Signature*

PATIENT'S RIGHTS

All patients shall have right’s which include, but are not limited to the following:

To be given a statement of services available by the agency and related charges.
To have access to the services, regardless of race, religion, sex or source of payment. -To have the right to request and receive an itemized and detailed explanation of the total bill for services rendered and products supplied.
To have access to the physician directing his/her care, information regarding his/her diagnosis, and treatment and prognosis.
To be allowed to participate in the “plan of care”, including discharge planning and to participate in decisions regarding his/her diagnosis, treatment or prognosis.
To be communicated to in a way that he/she can reasonably, expect to understand
To be informed about nature of any technical procedure that will be performed, as well as who will perform the procedure.
To have rights to refuse treatment (as permitted by law) and be informed of the medical consequence’s of such refusal.
To request to view policies and procedures of Fountain Valley Regional Sleep Center, Inc.
To seek assistance in finding and transferring the provision of services to another agency.
To receive care in a timely manner, appropriate to his/her needs.
To be treated with consideration, respect and full recognition of his/her dignity, individuality, and privacy. To be assured of confidentiality in treatment and records of such, and allowed to approve or refuse their release to any outside agencies.
To have competent and qualified personnel carry out the services for which they are responsible.
To be provided access to the state Health Department for problems about services.
To voice grievances and recommend changes in policies and services. The patient will be informed of Fountain Valley Regional Sleep Center, Inc. mechanism for receiving, and resolving patient complaints.
To be allowed to have patient’s family or guardian exercise the patient’s rights when patient has been judged incompetent.

Date*

Date

Signature*

PATIENT'S RESPONSIBILITIES

All patients shall have responsibilities, which include, but are not limited to the following:

To provide, to the best of his/her knowledge, accurate and complete information about present medications and/or other matters relating to his/her healthcare.
To report unexpected changes in his/her condition to those clinicians responsible for the management of his/her care.
To make it known whether he/she clearly understands a contemplated course of action and what is expected of him/her.
To inform Fountain Valley Regional Sleep Center, Inc. of any advance directive he/she may have.
To follow the treatment plan recommended for his/her care by the primary care physician and other allied health professionals, including nurses, pharmacists, and dieticians.
To keep appointments and, when unable to do so for any reason to notify Fountain Valley Regional Sleep Center, Inc. no later than 48 hours prior the scheduled appointment and make a new appointment.
To assume responsibility for his/her actions if he/she refuses treatment or does not follow the instructions as set forth by his/her primary care physician and the professional staff of Fountain Valley Regional Sleep Center, Inc..
To assure that the financial obligations of his/her health care are fulfilled as promptly as possible.
To be considerate of the rights of Fountain Valley Regional Sleep Center, Inc. personnel or representatives.
To be respectful of the property of Fountain Valley Regional Sleep Center, Inc and of its personnel.

Signature*

Date*

Date

SLEEP ASSESSMENT AND EPWORTH SCALE

(Questionnaire used to identify sleep disorder candidates)

Please list any medical problems with-in the last 5 years (hypertension, diabetes, surgeries, etc...)

Have you suffered from a Heart Attack?*

YesNo

When?*

Have you suffered from a Stroke?*

YesNo

When?*

Do you snore at night?*

YesNoOccasionally

Witnessed pauses in breathing while asleep*

YesNoOccasionally

Do you have difficulty falling asleep?*

YesNoOccasionally

Do you have difficult maintaining sleep?*

YesNoOccasionally

Experience a restless sensation in legs while lying awake*

YesNoOccasionally

Kicking and twitching movements while asleep*

YesNoOccasionally

Experience excessive daytime tiredness*

YesNoOccasionally

Have you ever awakened feeling paralyzed?*

YesNoOccasionally

Experience a sudden loss of strength in your arms or legs*

YesNoOccasionally

Were these brought on by a sudden frightening event or laughter?*

YesNoOccasionally

Do you frequently awaken with? Check all that apply*

According to the following scale choose the appropriate number value to represent how likely you are to fall asleep during the day in the following situations. Try to be as honest as possible. If possible have your significant other help you fill this out.

0-never 1-slight chance 2-moderate 3-always

Sitting and Reading*

	0	1	2	3

0 is Never, 3 is Always

Watching T.V.*

	0	1	2	3

0 is Never, 3 is Always

Sitting, inactive in a public place (movie, theater, meeting, etc.)*

	0	1	2	3

0 is Never, 3 is Always

Sitting and talking to someone*

	0	1	2	3

0 is Never, 3 is Always

Sitting quietly after lunch without alcohol*

	0	1	2	3

0 is Never, 3 is Always

As a passenger in a car for an hour without a break*

	0	1	2	3

0 is Never, 3 is Always

Driving a vehicle for two or more hours*

	0	1	2	3

0 is Never, 3 is Always

Signature*

Lying down to rest in the afternoon when circumstances permit*

	0	1	2	3

0 is Never, 3 is Always

Please total the amount from above:

PATIENT RECORD OF DISCLOSURE

I WISH TO BE CONTACTED IN THE FOLLOWING MANNER (CHECK ALL THAT APPLY)

Home Phone Number

Area CodePhone Number

Home Number

OK to leave a message with detailed informationLeave Message with a call back number only

Work Number

Area CodePhone Number

Work Number

OK to leave a message with detailed informationLeave Message with a call back number only

Cell Phone:

Area CodePhone Number

Cell Number

OK to leave a message with detailed informationLeave Message with a call back number only

Written Communication

OK to leave a message with detailed informationLeave Message with a call back number only

Canceled/ Missed Appointments:

A scheduled appointment means that time is reserved for you. If an appointment is missed or canceled with less than 48 working hours’ (two full working day’s) notice, a $150.00 fee will be billed to you

Patient's Initials:

Date*

Assignment of Benefits

I request that payment of authorized insurance benefits, including Medicare, if I am a Medicare beneficiary, be made on my behalf to the organization listed below for any equipment or services provided to me by that organization. I authorize the release of any medical or other information necessary to determine these benefits or the benefits payable for related equipment or services to the organization, the Health Care Financing Administration, my insurance carrier or other medical entity. A copy of this authorization will be sent to the Health Care Financing Administration, my insurance company or other entity if requested. The original authorization will be kept on file by the organization. I understand that I am financially responsible to the organization for any charges not covered by health care benefits. It is my responsibility to notify the organization of any changes in my health care coverage. In some cases exact insurance benefits cannot be determined until the insurance company receives the claim. I am responsible for the entire bill or balance of the bill as determined by the organization and/or my health care insurer if the submitted claims or any part of them are denied for payment. I understand that by signing this form I am accepting financial responsibility as explained above for all payment for products received. By signing this document, I also acknowledge that I have received a copy of the organization’s Notice of Privacy Practices. This acknowledgement is required by the Health Insurance Portability and Accountability Act (HIPAA) to ensure that I have been made aware of my privacy rights. ORGANIZATION FOUNTAIN VALLEY REGIONAL SLEEP CENTER 17150 Euclid Street Suite 300 Fountain Valley, CA 92708

Date*

Signature*