2940 Mallory Circle, Suite 204 - Celebration, FL 34747...2940 Mallory Circle, Suite 204 -...

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

http://www.floridalungdoctors.com/

1

Yes No Asthma

Bronchiectasis

Lung Cancer

Pneumonia

Pulmonary Emboli

Osteoarthritis

Rheumatoid Arthritis

Colitis

Hypertension

Seizures

Thyroid Problems

Sarcoidosis

Please explain any “YES” answers:

Yes No Emphysema

Pneumothorax

Pulmonary Fibrosis

Cancer

Diabetes

Valvular Heart Disease

Coronary Artery Disease (CAD)

Congestive Heart Failure (CHF)

Arrhythmia

Stomach Ulcers

Other (please describe below)

Please explain any “YES” answers:

Have you ever received (a) Pneumonia vaccine (b) Flu Shot?(Date)

Have you ever been diagnosed with any of the following? (Please check appropriate box)

Please list any surgeries and/or hospitalizations: Date Surgery/Hospitalization Location Doctor

Do you have: Living Will Power of Attorney; If yes, please provide a copy

Family Doctor (PCP):

Reason for visiting the doctor today?

Referring Doctor:

When did you first notice this problem?

Do you have any of the following? Please explain any “YES” answers here:





PATIENT MEDICAL HISTORY FORM

YOUR NAME AGE

Shortness of Breath YES NO

Wheezing YES NO

Hay Fever (Allergies) YES NO

Cough YES NO

Cough up Phlegm YES NO

Cough up Blood YES NO

Fevers YES NO

Recent Weight Change YES NO

Sleeping Disorder YES NO

Difficulty Swallowing YES NO

Chest Pain YES NO

Chest Tightness YES NO

How Long? # of Packs per day? Do you smoke? Yes No

Smoked in the past? Yes No How Long? When did you quit?


2

Review of Systems (please check box if you experience this symptom):

Constitutional: Eyes: Pulmonary: Ear, Nose & Throat:

Fatigue Fever Night Sweats Weight Loss Weight Gain

Need for Glasses Blurred Vision Double Vision Loss of Vision

Shortness of Breath Wheezing Cough

Psychiatric:

Depression Anxiety

Sore Throat Ear Ringing Decreased Hearing Dental Problems Oral Lesions Difficulty Swallowing Hoarseness

Cardiac: Endocrine: Musculoskeletal: Neurological:

Chest Pain Palpitations Leg Swelling

Thirst Heat/Cold Intolerance

Back Problems Joint Swelling Joint Pain

Dizziness Lethargy Passing Out Weakness Difficulty Speaking

Renal: Skin & Breast: Sleep-Related: Gastrointestinal:

Pain/Burning during Urinating Frequent Urination

Skin Lesions Rashes Breast Masses Discharge

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:





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


2

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your

usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would

have affected you. Use the following scale to choose the most appropriate number for each situation.

Answer Key: 0 = Would Never Doze

1 = Slight Chance of Dozing

2 = Moderate Chance of Dozing

3 = High Chance of Dozing

Situation Chance of Dozing

Sleep Questionnaire

Part II: The Epworth sleepiness Scale

1. Sitting and reading 0 1 2 3

2. Watching television 0 1 2 3

3. Sitting inactive in a public place (i.e., theatre or meeting 0 1 2 3

4. As a passenger in a car for an hour without a break 0 1 2 3

5. Lying down to rest in the afternoon when circumstances permit 0 1 2 3

6. Sitting and talking to someone 0 1 2 3

7. Sitting quietly after lunch without alcohol 0 1 2 3

8. In a car, while stopped for a few minutes in traffic 0 1 2 3

Part III: Please answer the following questions:

Do you work shifts or irregular hours? If yes, please explain:

Is there a history of sleep problems in your family? If yes, please explain:

Do you seem to sleep best at times different from most people you know? If yes, please explain:

Did you have sleeping problems during childhood (i.e., sleepwalking, night terrors, etc.) If so, please explain:

Do you drink caffeinated beverages (i.e., coffee, tea, colas)? If yes, how many per day?

Have you had any history of emotional or other psychiatric problems? If so, please explain:

Are there any other issues that you would like to bring to the doctor’s attention? If so, please explain:

Do you grind your teeth? Yes No

Do you have chronic nocturnal cough? Yes No

Do you have heartburn/reflux? Yes No

Do you fall out of bed? Yes No

Do your legs twitch/restless legs? Yes No





STOP BANG Questionnaire

Name: Age: Today’s Date:

Height: inches Weight: lbs. BMI

Collar size of shirt: S M L XL

Neck Circumference (measured by staff) inches

Please circle correct yes or no the following questions:

Snoring: Do you snore loudly (louder than talking or loud enough to be heard through closed doors)? Yes No

Tired: Do you often feel tired, fatigued, or sleepy during daytime? Yes No

Observed: Has anyone observed you stop breathing during your sleep? Yes No

Blood Pressure: Do you have or are you being treated for high blood pressure? Yes No

BMI more than 25? Yes No

Age over 50 years? Yes No

Neck circumference greater than 15.75 inches? Yes No

Gender, male? Yes No

* Neck circumference is measured by staff

High risk of Obstructive Sleep Apnea = answering “yes” to 3 or more questions

Low risk of Obstructive Sleep Apnea = answering “yes” to less than 3 questions

Adapted from: STOP Questionnaire: A Tool to Screen Patients for Obstructive Sleep Apnea Frances Chung, F.R.C.P.C., Balaji Yegneswaran, M.B.B.S., Pu Liao, M.D., Sharon A. Chung, Ph.D., Santhira Vairavanthan, M.B.B.S., Sazzadul Islam,

M.Sc., Ali Khajehdehi, M.D., Colin M. Shapiro, F.R.C.P.C.

Anesthesiology 2008; 108:812-21 Copyright 2008, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.


Disclaimer of Liability:

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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





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.

Patient Signature Date


http://www.hhs.gov/





Assignment of Benefits

In order for Florida Lung, Asthma & Sleep Specialists, PA to bill Medicare and/or

other insurance(s) for your medical care, please complete, sign and date this form.

In consideration of the medical services provided to me, I hereby assign and transfer to

Florida Lung, Asthma & Sleep Specialists, PA, (FLASS), all medical provider benefits

payable and any related rights existing under the insurance policies described (but not

to exceed the amount of charges for this period of service.) I authorize and direct my

insurance company to pay all such benefits to FLASS. I understand that this assignment

does not relieve me of any responsibility I may have for payment of charges not paid by

my insurance company, unless otherwise provided by the terms of an agreement

between the insurer and FLASS.

I have read and fully understand the above statement:

Patient Name: ____________________________________________________________________(Please Print)

Patient Signature: ______________________________________________________________

Date: ___________________________________________________________________________






YOUR HEALTH INSURANCE

As you know, significant changes are currently taking place in the health care industry.

Hundreds of individual health care companies each offer multiple plans, any one of which may alter their

coverage at any time. We try to stay current, but it’s virtually impossible to be aware of the details of each

plan, especially when they change suddenly and without prior notice.

Please contact your insurance company prior to your visit to insure we are in-network providers for your

particular plan. Please provide the insurance company with our NPI number 1316228364. Also, please be

aware of your deductible and your co-pay, as well as whether your plan covers any particular service about

which you may have a question.

Your health insurance is a contract between you and your insurance company. You, as the policy holder,

are ultimately responsible for issues regarding your insurance coverage. We will assist you as best we can

with questions you may have about your plan.

Please acknowledge your understanding of the content of this memo by initialing here .

Let us know if you have any questions.

Thank you.


2940 Mallory Circle, Suite 204 - Celebration, FL 34747 – Fax: 407-507-2616

4553 Pleasant Hill Road – Kissimmee, FL 34759 – Fax: 407-910-4759

717 East Michigan Street – Orlando, FL 32806 – Fax:407-515-8584

700 SR 60 East – Lake Wale, FL 33853 – Fax: 863-949-6993

AUTHORIZATION FOR USE AND/OR DISCLOSURE OF

PROTECTED HEALTH INFORMATION

(MEDICAL RECORDS)

PLEASE FILL IN ALL SECTIONS

By signing this Authorization, I hereby authorize and permit the use and/or disclosure of my protected health information (medical record) for the

purpose(s) described in this form. I understand that this Authorization is completely voluntary and I am signing it under my own free will.

Providing / Receiving this information (circle one):

Providing / Receiving this information (circle one and fill in name/organization in box below):

PLEASE SEND THE FOLLOWING MEDICAL RECORDS:

*The following items will NOT be included/will not be sent unless initialed next to each item:

* HIV/AIDS related health information and/or records.

* Mental health information and/or records.

*Genetic testing information and/or records.

*Drug/alcohol diagnosis, treatment and/or referral information (Federal regulations require a description of how much and

what kind of information is to be disclosed Federal law prohibits the disclosure of such information.)

1. Staff must complete the following:

a. What is the purpose of the use or disclosure? (Check one.)

AT THE PATIENT’S REQUEST OR LEGAL REPRESENTATIVE’S REQUEST

Other (describe):

2. The patient or the patient’s representative must read and initial the following statements:

a. I understand that my health care and the payment for my health care will NOT be affected if

I DO NOT sign this form Initial_______b. I understand that I may see and copy the information described on this form if I ask for it,

And that I may request a copy of this form after I sign it. Initial_______

1. I understand that this Authorization will not expire unless I contact your office. Initial_______

Signature of Patient or Patient’s Representative

Print Name of Patient’s Representative:

Relationship to Patient:

Reason Authorization is signed by the Patient’s Representative:

SECTION A: Must be completed for ALL Authorizations

Patient Name: Last 4-digits SS#

Home Address:_ Date of Birth:

Florida Lung, Asthma & Sleep Specialists, PA Fortune Alabi, MD, Fred Umeh, MD, Maximo Lama, MD

Irtza Sharif, MD, Don Elton, MD, Nelson Medina-Villanueva MD, Bassam Doujaiji, MD

Medical records, test results, lab reports and other records which are pertinent to my care at this office.

SECTION B:

SECTION C: Must be completed for ALL Authorizations

X SIGN HERE: DATE:


2940 Mallory Circle, Suite 204 - Celebration, FL 34747...2940 Mallory Circle, Suite 204 -...

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