- American Sleep Medicine

For the fastest, most prompt service possible, American Sleep Medicine has provided our patient sign-in documentation and forms here for your convenience. Please review our welcome letter and disclosures here, then scroll below to review steps for preparation along with forms to submit your patient health information safely and securely. 051202

If you encounter any trouble at all with this process, we are happy to assist - we are available by telephone, e-mail and in-person.

For assistance, locate our nearest location here

Welcome and Disclosures

Welcome to American Sleep Medicine
Review our Privacy Policy

Patient Rights & Responsibilities
Independant Testing Facility Performance Standards

Items To Bring For Your Sleep Study

Please review the list below and feel free to ask our center team if you have any questions:

ITEMS TO BRING:

Driver’s License
Insurance Card
Medication
Medication List
Light Overnight Bag
Reading Material\Glasses
2 Piece Pair of Pajamas
Toothbrush\Mouthwash
Shampoo\Conditioner
Personal Hygiene Products
Slippers (if you choose)
Any out of pocket payment due

ITEMS & SERVICES WE PROVIDE:

Satellite Television
Adjustable Reverie Bed
Muffins/Coffee/Juice in the Morning
Intercom Service
Reading Lamp
Overnight Baggage Storage
Registered Technicians & Respiratory Therapists
Bi-Lingual Staff
Private Room for your Caretaker to Stay (if needed)
Free Parking & Security
Bathroom
Emailed or Faxed Paperwork

UPON REQUEST, WE HAVE:

Female or Male Technician
Extra Blankets
Extra Pillows
Extra Towels
Night Light
Portable Fan
Clothes Hangers
Disposable Razor
Toothpaste\Mouthwash
Plastic Water Cups
Bottled Water\Soda\Coffee
Portable Heater
Ear Plugs

DO NOT BRING:

Valuables (jewelry or large sums of money)
Perishable Food
Strong Perfumes or Cologne
Alarm Clock (we will wake you up)
Pets (does not apply to service animals)

Please let us know if you have any disabilities or special needs that we should know about prior to your study. Due to the products we use to attach each lead, you will need to wash your hair following the study. If there is anything else we can do to make your stay more enjoyable, do not hesitate to ask. We want to provide you with the best experience possible!

Facility Selection

Which American Sleep Medicine Facility are you checking into?

Patient Information

Referring Physician:

Name of Patient:

Patient Gender:

Home Address:

Home City:

Home State:

Home ZIP Code:

Marital Status:

Single

Married

Divorced

Separated

Widowed

Home Telephone:

Cell Phone:

Social Security #:

Patient Age:

Patient Date of Birth:

Employment (if applicable):

Business Telephone:

Employer Address:

Employer City:

Employer State:

Employer ZIP Code:

Guardian Informaiton

Name of Patient:

Patient Gender:

Home Address:

Home City:

Home State:

Home ZIP Code:

Marital Status:

Single

Married

Divorced

Separated

Widowed

Home Telephone:

Cell Phone:

Social Security #:

Guardian Age:

Guardian Date of Birth:

Employment (if applicable):

Business Telephone:

Employer Address:

Employer City:

Employer State:

Employer ZIP Code:

Nearest Relative Name (not at same address as patient):

Nearest Relative Relationship (Brother, Sister, etc):

Nearest Relative Phone Number:

This information is not needed for patients 18 years of age and older.

Primary Insurance Information

Insurance Company Name:

Insurance Member ID #:

Insurance Group #:

Insurance Policy Effective Date:

Insurance Subscriber Name (Policy Holder):

Insurance Subscriber Date Of Birth:

Insurance Subscriber Social Security #:

Patient Relationship to Subscriber:

Self

Spouse

Child

Other

Check this box if you need to provide additional insurance information.

Insurance Company Name:

Insurance Member ID #:

Insurance Group #:

Insurance Policy Effective Date:

Insurance Subscriber Name (Policy Holder):

Insurance Subscriber Date Of Birth:

Insurance Subscriber Social Security #:

Patient Relationship to Subscriber:

Self

Spouse

Child

Other

* TRICARE: IF THE PRIMARY INSURANCE IS TRICARE, WE MUST HAVE THE SOCIAL SECURITY NUMBER AND DATE OF BIRTH OF THE INSURANCE SPONSOR IN ORDER TO FILE A CLAIM ON YOUR BEHALF.

** A COPY OF YOUR INSURANCE CARD(S) IS REQUIRED TO BE PRESENTED ON OR BEFORE THE DATE OF SERVICE.

DISCLOSURES AND AUTHORIZATIONS

Patient Consent for Treatment

	I am requesting American Sleep Medicine (“ASM”) to test me for possible sleep disorders and I authorize ASM to provide such tests as set forth in the physician order.
	I understand that photographs, video, digital or other images may be recorded to document my care and I explicitly provide my consent. I understand ASM retains the ownership rights to any such recorded images and I understand I am able to view or obtain copies. I understand these recorded images will be stored in a secure manner to protect my privacy as part of my medical record and will be kept for the time required by law.
	I acknowledge I have consulted my physician and understand the nature of the test(s) and consent to such sleep tests.

Patient Assignment of Benefits Agreement

	I authorize direct remittance of payment of all insurance or Medicare benefits to ASM for all covered services, and I authorize ASM to act as my Designated Representative concerning all aspects of insurance claim filing, including, but not limited to, appeals for products or services rendered by ASM. I understand and agree that my Assignment of Benefits will have continuing effect for as long as I am receiving services from ASM. I authorize my insurance company to mail ALL PAYMENTS directly to ASM.
	I understand that I ultimately have the financial responsibility for the payment of all fees associated with the services provided by ASM. I will be responsible for all charges not covered by my insurance and if I receive any payment from my insurance carrier directly for services rendered by ASM, I will immediately forward such payment to ASM.
	I understand the Estimated Out of Pocket Expenses are due prior to receiving any services or products. The ASM billing department can be reached directly at 1-877-526-8296 for any billing-related questions.
	I understand that the physician’s consult, follow-up, and reading of the study will be billed separately.

Past Due Accounts

I understand that a fee may be charged by ASM on all accounts that are 90 days or more past due. ASM may charge interest on any outstanding balance more than 90 days past due at a rate of onehalf (1/2) percent per month. I understand the interest rate fee may be added to any account that is more than 90 days past due and hereby agree to pay any and all such charges. I also understand that in the event my account is placed with a collection agency, and/or a lawsuit is brought against me to collect any outstanding balance due ASM, I will be responsible for all costs of collections, including, but not limited to, court costs and reasonable attorney fees.

Reschedule/No-Show Fee

I understand that if I do not notify ASM more than 24 hours prior to my scheduled test appointment that I cannot attend, I may be charged $75.00 fee.

Commercial Drivers

I understand if I am diagnosed with a sleep disorder, the agency that has issued my commercial driver’s license may be contacted if I do not follow my doctor’s instructions and recommendations or if I am not compliant with my treatment plan.

Receipt of Notice of Privacy Practices, Patient Rights and Responsibilities, and Provider Performance Standards

I have received and reviewed the attached Notice of Privacy Practices, the Patient Rights and Responsibilities, and the Provider Performance Standards; I understand my rights as stated in these documents.

I have read and I understand each section. My initials and signature represent my unqualified acceptance and acknowledgement of each of the above statements. I authorize a copy of this form to be used in place of the original.

Patient Consent for Use and Disclosure of Protected Health Information

This request of your consent will not restrict the normal use or disclosure of your protected health information necessary by American Sleep Medicine for the purpose of providing treatment, obtaining payment or supporting the day-to-day health care operations of the clinic.

By signing this disclosure, I consent that the clinic may call my home or other designated location and leave a message on voicemail or in-person in reference to appointment reminders and insurance items. In addition, the clinic may mail to my home appointment reminders and patient statements.

I designate the following individual(s) who the clinic staff or billing staff can communicate with on my behalf. If I do not designate anyone, I understand that the clinic staff or billing staff will be unable to speak with anyone regarding my medical condition or insurance billing.

Name:

Relationship:

Phone:

Name:

Relationship:

Phone:

Name:

Relationship:

Phone:

Mark Agreed to Confirm Signature for this section

AUTHORIZATION FOR MINOR PATIENTS
(PATIENTS UNDER 18 YEARS OF AGE)

I authorize the treatment of my minor child, _Auto-Filled_____________, by American Sleep Medicine.

I understand that as the parent/guardian presenting this minor for treatment, I am personally financially responsible for payment of the account, regardless of any divorce, custody order or legal arrangements.

I authorize American Sleep Medicine to act as my agent in helping me obtain payment from this minor's insurance companies.

I authorize use of this form on all insurance submissions.

I authorize release of information (including the minor’s health information and billing information) regarding all services rendered.

I understand it is my responsibility to obtain a referral from this minor's primary care physician (if required by the insurance company) and that if payment is not made due to lack of a referral, I am personally financially responsible for payment of the account.

I authorize a copy of this Authorization to be used in place for the original.

Mark Agreed to Confirm Signature for this section

ADMISSION SLEEP QUESTIONARRE

It is important that you fill out this sleep questionnaire completely and as accurately as possible. Please answer each question. The questionnaire is a broad-based screening tool that will assist our staff and your treating sleep physician to provide excellent care to you. It may be helpful to consult with a family member or bed partner when answering these questions. All information contained in this questionnaire will become a part of your medical record and will be confidential.

DEMOGRAPHIC DATA

Height:

Weight:

PHYSICIAN INFORMATION

Primary Physician Name:

Address (Street):

Address (City/State/ZIP):

Phone:

Specialty:

Requesting Physician Name:

Address (Street):

Address (City/State/ZIP):

Phone:

Specialty:

SLEEP SCHEDULE

Weekday Bedtime:

Weekday Wake Time:

Weekday Average Sleep Time:

Weekend Bedtime:

Weekend Wake Time:

Weekend Average Sleep Time:

Do you wake up feeling rested?

Do you currently use CPAP treatment at night?

Pressure:

Do you have rotating or night shift work?

How long does it take you to go to sleep?

How many times a night do you wake up from sleep?

Do you fall back to sleep easily?

Do you nap?

If so, how often?

SLEEP HISTORY

Describe the problem you are experiencing with your sleep and when it first began:

	Do you experience excessive daytime sleepiness?
	Are you a restless sleeper?
	Has anyone told you that you snore?	For how long?
	Do you snore sleeping in all positions?	For how long?
	Has your family told you that you quit breathing at night?	For how long?
	Have you ever awakened gasping for breath?	For how long?
	Do you awaken with mouth dryness?	For how long?
	Do you have morning headaches?	For how long?
	Has your weight changed in the last 5 years?	How much weight?
	Do you have “tingly” legs and feel as if you have to move them?	For how long?
	Do you kick your legs at night?	For how long?
	Do you sleep better away from your own bed? (ie: vacation)	For how long?
	Do you have pain that bothers you at night?	For how long?
	Do you grind your teeth in your sleep?	For how long?
	Do you sleep walk?	For how long?
	Do you talk in your sleep?	For how long?
	Have you ever experienced periods in which you feel paralyzed while you are going to sleep or waking up?	For how long?
	Have you ever had a hallucination or dream-like mental images when falling asleep?	For how long?
	Have you ever experienced sudden physical weakness during strong emotions? (ie: legs going limp while laughing or when angry)	For how long?
	Do you have difficulty staying awake to drive?	For how long?
	Have you ever had an automobile accident due to sleepiness?	Date of Accident?

PAST MEDICAL HISTORY

Please select all that apply:

MEDICATIONS

Medicine Name:

Dose:

Medicine Name:

Dose:

Medicine Name:

Dose:

Medicine Name:

Dose:

Medicine Name:

Dose:

Medicine Name:

Dose:

Medicine Name:

Dose:

Medicine Name:

Dose:

Over the counter medications:

Medication Allergies:

Are you currently using supplemental oxygen?

What LPM?

SOCIAL HISTORY

Caffeine

How much caffeine do you consume on a daily basis?

Caffeinated beverage (cola, soda, etc.)
How many cans per day?

Tea or Coffee
How many cups per day?

Tobacco

Never Quit Currently Smoke Currently Chew

How many packs per day?
How many years?

FAMILY HISTORY

Family History including father, mother, and siblings:

SYMPTOMS REVIEW

Please select all that apply below:

Other complaints not mentioned above:

Mark Agreed to Confirm Signature for this section

EPWORTH SLEEPINESS SCALE

Your physician has asked that you complete the following Epworth Sleepiness Scale. Your answers to the questions below will be used to measure how sleepy you are generally, and will be used by your physician as an aid in determining your diagnosis and treatment.

How likely are you to doze off or fall asleep in the certain situations, in contrast to just feeling tired?

This refers to your usual way of life in recent times. If you have not done some of these things recently, think about how they have affected you in the past.

Use the following scale to choose the most appropriate number for each situation:

0 = no chance of dozing
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing

It is important that you answer each question as best you can.

Situation	Chance of Dozing (0-3)
Sitting and reading
Watching TV
Sitting, inactive in a public place (e.g. a theatre or a 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 a lunch without alcohol
In a car, while stopped for a few minutes in the traffic

THANK YOU FOR YOUR COOPERATION

2020 PRE-SLEEP APNEA QUALITY OF LIFE QUESTIONARRE

0 = Never
1 = Small Amount
2 = Small to Moderate Amount
3 = Moderate Amount
4 = Moderate to Large Amount
5 = Large Amount
6 = Very Large Amount

Question	Answer (See scale above)
How much of the time have you had to push yourself to remain alert during a typical day (work, school, childcare, housework)?
How often have you had to use all of your energy to accomplish your most important activity (work, school, childcare,housework)?
How much difficulty have you had finding the energy to do other activities (exercise, relaxing, etc)?
How much difficulty have you had trying to stay awake?
How much of a problem has it been to be told your snoring is irritating?
How much of a problem have frequent conflicts or arguments been?
How often have you looked for excuses for being tired?
How often have you not wanted to do things with your family/friends?
How often have you felt depressed, down, or hopeless?
How often have you been impatient?
How much of a problem has sleepiness been as an everyday issue?
How much of a problem have you had with decreased energy?
How much of a problem have you had with fatigue?
How much of a problem have you had waking up feeling unrefreshed?

HEALTH INFORMATION RELEASE AUTHORIZATION (OPTIONAL)

Name:

Date Of Birth:

Social Security #

Address:

City:

State:

ZIP Code

Day/WOrk Telephone:

RELEASE INFORMATION – CHOOSE ONE BOX

⁭I authorize American Sleep Medicine to RELEASE medical records information to:

⁭ I authorize American Sleep Medicine to OBTAIN medical records information from:

Name:

Address:

City:

State:

ZIP Code

PURPOSE FOR REQUEST

Continued Care

Attorney

Personal Use

Insurance Claim

Other

I understand that I am entitled to ONE FREE COPY of my medical records during my lifetime. Any additional copies sent for any reason are subject to a copy fee of $1 per page.

This is the first requested copy of my medical records

INFORMATION NEEDED

Entire Medical Record

Laboratory Results

Test Results

Progress for Dates:

Other:

I understand that the information in my health record may include information related to sexually transmitted disease acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behaviors or mental health services and treatment for alcohol and/or drug abuse.

AUTHORIZATION

This authorization is effective for the duration of my treatment unless revoked or terminated by the patient or the personal representative. It is understood that my records may not be released to me at the same time as requested. It can take anywhere from 24 hours to 30 days from the time of the request

I may revoke or terminate this authorization by contacting American Sleep Medicine in writing. I understand that revocation will not apply to information that has already been released in response to this authorization. Information that is disclosed under this authorization may be disclosed again by the person or organization to which it is sent. The privacy of this information is in compliance with the Health Insurance Privacy and Portability Act of 1996 (HIPPA).

Signer's Relationship To Patient:

Mark Agreed to Confirm Signature for this section

Packet e-Signature

I am agreeing that all data provided on these forms are truthful and complete to the best of my knowledge. I also agree to be bound by, and witness that I understand fully the terms and policies shown herein. In substitution of a written signature, I will provide an "e-Signature" by entering today's date in the following input box and pressing the SUBMIT button below.

	Condition	Relations? (ex: Mom, Dad, Brothers)
	Diabetes
	High B/P
	Stroke
	Narcolepsy
	Depression

	Condition	Relations? (ex: Mom, Dad, Brothers)
	Obesity
	Snoring
	Sleep Apnea
	Daytime Fatique
	Anxiety

New Patient Sign-In

Welcome and Disclosures

Items To Bring For Your Sleep Study

ITEMS TO BRING:

ITEMS & SERVICES WE PROVIDE:

UPON REQUEST, WE HAVE:

DO NOT BRING:

Facility Selection

Patient Information

Guardian Informaiton

Primary Insurance Information

DISCLOSURES AND AUTHORIZATIONS

Patient Consent for Treatment

Patient Assignment of Benefits Agreement

Past Due Accounts

Reschedule/No-Show Fee

Commercial Drivers

Receipt of Notice of Privacy Practices, Patient Rights and Responsibilities, and Provider Performance Standards

Patient Consent for Use and Disclosure of Protected Health Information

AUTHORIZATION FOR MINOR PATIENTS (PATIENTS UNDER 18 YEARS OF AGE)

ADMISSION SLEEP QUESTIONARRE

DEMOGRAPHIC DATA

PHYSICIAN INFORMATION

SLEEP SCHEDULE

SLEEP HISTORY

PAST MEDICAL HISTORY

MEDICATIONS

SOCIAL HISTORY

FAMILY HISTORY

SYMPTOMS REVIEW

EPWORTH SLEEPINESS SCALE

THANK YOU FOR YOUR COOPERATION

2020 PRE-SLEEP APNEA QUALITY OF LIFE QUESTIONARRE

HEALTH INFORMATION RELEASE AUTHORIZATION (OPTIONAL)

RELEASE INFORMATION – CHOOSE ONE BOX

PURPOSE FOR REQUEST

INFORMATION NEEDED

AUTHORIZATION

AUTHORIZATION FOR MINOR PATIENTS
(PATIENTS UNDER 18 YEARS OF AGE)