Core Sleep Solutions/TMJ of AZ New Patient IntakeTodays date
First Name______Last Name ______Middle Initial ______
Address ______City______Zip Code______
Date of Birth______Male ( ) Female ( ) Social Security#______
Ethnicity & Race( ) White ( ) African American ()Hispanic or Latino ( ) Other
Married Single Divorced
Contact Information: Home______Cell______
Email address ______
Primary Insurance Carrier______Group #______
Subscriber Name______Member Id______
Group Name (Employer) ______Subscriber DOB______
Relationship to patient______
Secondary Insurance carrier______Group#______
Subscriber Name ______Member Id______
Group Name (Employer) ______Subscriber DOB______
Relationship to patient______
How did you hear about our office?______
SLEEP CHIEF COMPLAINTS (Please circle all that apply)Do you have any of the following?___
Excessive daytime sleepinessPain when chewing Limited mouth opening
SnoringClenchingGrinding teeth
Gasping/choking during sleepJaw ClickingLocking/popping
Un-refreshed sleepFacial painHeadaches
Difficulty falling asleepNeck painEar pain LT or RT
Difficulty staying asleepJaw painLT or RT
Sleepiness while drivingRinging earsLT or RT
Decreased concentrationClogged earsHeadaches
Impaired thinkingEye painShoulder pain
Not dreaming
Insomnia
How many hours per night do you typically sleep?______
Have you ever had a lab or home sleep study? ______When? ______
Have you been diagnosed with Sleep Apnea or any other sleep disorder?______
Current Medications______
ALLERGIES______
Major Medical History: (please circle all that apply)
AsthmaCOPD
Heart DiseaseStroke
Heart attackBlood clots
Head injuriesCancer
HIV/HepatitisDiabetes
OTHER______
Family History (please circle all that apply)
Cancer Thyroid Diabetes Obesity Father Snores Mother Snores Heart disease High Blood Pressure
Father Has sleep apnea Mother has sleep apnea Other sleep disorder______
Do you currently smoke?_____ How much? ______Are you a previous smoker?______
Alcohol____ beer __wine_____ other____how often______
Caffeine use______
Hospitalizations/Surgeries/Injuries______
Symptoms checklist (please circle all that apply)
Eyes: Contacts Glasses Blurred Vision Eye Pain
Ear, Nose, Mouth, Throat: Dry mouthHearing lossNasal congestion
Neck painOral painTrouble swallowing
Cardiovascular: Chest pain/pressure at restChest pain/pressure with exertion
Cold hands/feet Palpitations Fainting Hypertension
Respitory:Wheezing Shortness of breath Chest pain Cough Asthma COPD
Musculoskeletal: Joint pain Joint stiffness Muscle weakness
Muscle painArthritis
Neurological:Dizziness Headache Numbness Speech Disturbance Tingling Parkinson's Alzheimer's
Psychiatric: Anxious Nervous Depressed
Dental History
Last dental exam/cleaning ______Last dental x-rays ______
Are you scheduled for any dental work in the near future? ______
If yes, what kind of work is being performed? ______
Primary Care Doctor______
Pulmonologist/Cardiologist/Neurologist______
Authorization to Release and Request Information
By my signature, I hereby knowingly and voluntarily authorize Core Sleep Solutions to use or disclose my health information as necessary for payment of medical claims. I understand that coordination of care between Core Sleep Solutions and my other medical providers is essential for treatment and I allow communication of my health information/medical records between providers. I understand that records from other providers or hospitals contained within my chart must be obtained from that provider or hospital.
Patient Name: ______DOB:______
Financial Policy
Payment is due at the time of service unless arrangements have been made prior to the start of treatment. We accept Cash, Check, Debit / Credit Cards: MasterCard, Visa, Discover and American Express.
Insurance balances are ultimately the patient’s obligation. We will file primary and secondary medical claims as a courtesy. Some of your treatment may not be covered by your insurance carrier. The cost for such charges as copays/coinsurance/deductible will be your patient responsibility.
Patient balances that are neglected may be forced to an outside collections agency for collection. In this event, it is agreed that the patient will be responsible for interest charges and/or collection fees up to 35% of the principal balance. There are additional fees for returned checks as NSF (Non-sufficient funds)
Core Sleep Solutions staff will estimate the cost of your out of pocket expenses to the best of our ability with the insurance coverage information quoted by your insurance plan.
***FREE SLEEP EXAM/SCREENING***Our office does not charge the Home Sleep Test to the insurance company. The patient is responsible for Office Visit Copays, Deductibles and Coinsurance costs that may be applied specific to your medical plan coverage.
We ask that you kindly give 24 hours’ notice if you will not be able to keep your appointment. We reserve the right to charge for excessive last minute cancellations and no-shows.
Signature of Patient______
Printed name______
Date______Staff Initials______
NOTICE OF HIPAA PRIVACY PRACTICES ACKNOWLEDGEMENT AND DESIGNATIONS
PATIENT CONSENT FORM
Under Health Insurance Portability & Accountability Act of 1996 (HIPAA), you have certain right to privacy, which are outlined in the HIPAA form provided. This information will be used to:
- Plan, conduct and direct your treatment and follow-up among multiple health care providers involved in your treatment.
- Obtain payment from third party payers.
- Conduct normal healthcare operations such as quality assessment and Physician certification.
You have the right to review NOTICE OF PRIVACY PRACTICES prior to signing this consent. This organization has the right to change its Notice of Privacy Practices from time to time and that you may contact this organization at any time to obtain a copy of the Notice of Privacy Practices.
You may revoke this consent in writing at anytime.
Name of Patient (Please print) ______
Signature of Patient / Parent/Guardian______Date______
Relationship______