Patient Registration

Please fill in your personal and insurance information completely.

* Indicates a required field

Patient Demographics

First Name *

Last Name *

Middle Initial

Date of Birth *

Age

Sex

Male Female Other

Social Security #

Driver's License #

Street Address

City

State

Zip Code

Home Phone

Cell Phone

Email Address *

Marital Status

Single Married Divorced Widowed

Employer

Occupation

Emergency Contact

Contact Name

Relationship

Contact Phone

Insurance Information

Primary Insurance Company

Policy Holder Name

Relationship to Patient

Member ID #

Group #

Secondary Insurance (if any)

Secondary Member ID #

Primary Care Provider (PCP)

Referring Provider

Preferred Pharmacy

Pharmacy Name

Pharmacy Address

Pharmacy Phone

Consent to Treat

Please read carefully and sign below.

Consent to Treatment

I hereby consent to and authorize West Coast Sleep Clinic and its physicians, nurses, and medical staff to provide medical evaluation, diagnosis, and treatment that they deem appropriate for my care. I understand that the practice of medicine is not an exact science, and that no guarantees or assurances have been made regarding the outcome of any treatment or procedure.

I consent to physical examinations, diagnostic tests (including blood draws, sleep studies, imaging, and other procedures), medical treatments, and the administration of medications as deemed necessary by the treating physician.

I understand that I may refuse any treatment or procedure at any time, and that I have the right to ask questions about any recommended treatment before consenting to it. I have the right to be informed about my diagnosis, the nature and purpose of any proposed treatment, the risks and benefits, and any alternative treatments available.

I acknowledge that I have received and reviewed the Notice of Privacy Practices describing how my protected health information may be used and disclosed. I authorize West Coast Sleep Clinic to use my health information as described in that notice.

I authorize West Coast Sleep Clinic to bill my insurance company or other third-party payer on my behalf for services rendered. I understand that I am ultimately responsible for any charges not covered by my insurance.

I have read and understand the Consent to Treatment above, and I consent to the treatment and authorization described.

Patient (or Guardian) Signature *

Date

Financial Policy

Please read our financial policy and acknowledge below.

Patient Financial Policy

Co-pays, Deductibles & Co-insurance: All co-pays, deductibles, and co-insurance amounts are due at the time of service. We accept cash, check, and major credit/debit cards.

Insurance Billing: We will bill your insurance company as a courtesy. You are responsible for ensuring that we have current and accurate insurance information. If your insurance does not pay within 60 days, the balance will become your responsibility.

Non-Covered Services: Some services may not be covered by your insurance plan. You will be financially responsible for these services.

Referrals & Prior Authorizations: If your insurance requires a referral or prior authorization, it is your responsibility to obtain this before your visit. Failure to do so may result in non-payment by your insurance, and you will be responsible for the full balance.

Self-Pay Patients: Payment is due in full at the time of service. Please contact our billing office to discuss payment arrangements if needed.

Returned Checks: A fee of $35.00 will be charged for any returned checks.

Cancellations: We require 24 hours notice for appointment cancellations. Repeated late cancellations or no-shows may result in a fee.

I have read and understand the Financial Policy above, and I agree to abide by its terms.

Patient (or Guardian) Signature *

Date

HIPAA Notice of Privacy Practices

Your privacy is important to us. Please review our Notice of Privacy Practices.

Notice of Privacy Practices — Acknowledgment

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Our Commitment to Your Privacy: West Coast Sleep Clinic is dedicated to maintaining the privacy of your protected health information (PHI). We are required by law to maintain the privacy of your PHI and to provide you with this notice regarding our legal duties and privacy practices.

How We May Use Your Information: We may use or disclose your PHI for treatment purposes (such as sharing information with other providers involved in your care), payment purposes (such as billing your insurance company), and healthcare operations (such as quality assessment and improvement activities).

Your Rights: You have the right to:

Request a restriction on uses and disclosures of your PHI
Request confidential communications
Inspect and copy your PHI
Request an amendment to your PHI
Receive an accounting of disclosures
Receive a copy of this notice

Complaints: If you believe your privacy rights have been violated, you may file a complaint with our Privacy Officer or with the U.S. Department of Health and Human Services. We will not retaliate against you for filing a complaint.

I acknowledge that I have received and reviewed the Notice of Privacy Practices for West Coast Sleep Clinic.

If you are signing on behalf of the patient, please explain your relationship:

Patient (or Representative) Signature *

Date

Text & Telehealth Consent

Please read and agree to the following communication consents.

Text Message Consent

Consent to Receive Text Messages

By signing below, you consent to receive text messages (SMS) from West Coast Sleep Clinic at the mobile phone number(s) you have provided. These messages may include appointment reminders, health information, billing notifications, and other practice communications.

Message and data rates may apply. Message frequency varies. You may opt out at any time by replying STOP to any text message. Reply HELP for help. Carriers are not liable for delayed or undelivered messages.

Text messaging is not a secure form of communication. By consenting, you understand and accept the risk that text messages may be intercepted. Do not send sensitive medical information via text message.

I consent to receive text messages from West Coast Sleep Clinic as described above.

Best Cell Phone for Texts

Telehealth Consent

Consent to Telehealth Services

Telehealth involves the use of electronic communications to enable healthcare providers to provide clinical services to patients using interactive audio, video, or data communications. I understand that telehealth services involve the communication of my personal medical information, both orally and visually, to healthcare practitioners located in other areas.

Risks & Benefits: I understand there are potential risks with telehealth including interruptions, unauthorized access, and technical difficulties. I understand that my healthcare provider may determine that the transmitted information is of insufficient quality to make medical or health decisions, and that I may need an in-person visit.

Confidentiality: I understand that the laws that protect the privacy and security of my health information apply to telehealth services. West Coast Sleep Clinic will take steps to ensure my information is secure.

I understand I may refuse telehealth services at any time without affecting my right to future care or treatment.

I consent to telehealth services as described above and understand the risks and benefits associated with receiving care via telehealth.

Patient (or Guardian) Signature *

Date

Authorization to Release Medical Information

Complete this form to authorize release of your medical records.

This authorization allows West Coast Sleep Clinic to release your medical records. You may leave optional fields blank if not applicable. You have the right to revoke this authorization at any time by notifying us in writing.

Release To

Name or Organization *

Phone / Fax

Address

Information to Release

Entire Medical Record Office Visit Notes / Progress Notes Lab Results Imaging / Radiology Reports Sleep Study Reports Prescription / Medication History Billing Records Other:

Other (specify)

Details

Purpose of Release

Date Range of Records

Authorization Expiration Date

No Expiration (one-year default)

I authorize the release of the medical information described above. I understand I may revoke this authorization at any time in writing. I understand that a photocopy or electronic copy of this authorization is as valid as the original.

Patient (or Guardian) Signature *

Date

Patient Questionnaire

This helps our physicians understand your health history and sleep concerns.

Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following situations?
0 = Would never doze 1 = Slight chance 2 = Moderate chance 3 = High chance

Situation	0	1	2	3
Sitting and reading
Watching TV
Sitting inactive in a public place
As a passenger in a car for an hour
Lying down in the afternoon when possible
Sitting and talking to someone
Sitting quietly after lunch (no alcohol)
In a car stopped for a few minutes in traffic

Medications & Allergies

Current Medications (include dosages if known)

Known Drug Allergies

Additional Information

Height

Weight

Additional Comments or Concerns

Patient Registration