METROPLEX PULMONARY SLEEP CENTER, P.A. …mpsleepcenter.com/PDF_Files/new_patient_forms.pdfMETROPLEX PULMONARY &SLEEP CENTER, P.A. 4833 Medical Center Drive, Suite 6-B McKinney, Texas

METROPLEX PULMONARY &SLEEP CENTER, P.A.4833 Medical Center Drive, Suite 6-B

McKinney, Texas 75069Phone: (972) 838-1892 Fax: (972)838-1896

PATIENT HISTORY FORMName: ____________________________ Today’s Date:_________________Date of Birth: ______________________ Age:_________________________

Describe the current medical problem or reason for today’s visit:________________________________________________________________________________________________________Have you had any recent CT Scans, x-rays or lab tests, relating to this problem? __Yes __NoIf yes, when and where were they done? _____________________________________________

Who is your primary care physician? _______________________________________________Who is your referring physician for today’s visit? _____________________________________

Have you ever been diagnosed with the following?___ Asthma __ Heart Attack __ Sleep Apnea__ Thyroid Disease___ Chronic Bronchitis __ Stroke __ Kidney Disease __ High Cholesterol___ Emphysema __ Hypertension __ Gastric Ulcers __ Congestive Heart ___ Pneumonia __ Diabetes__ Hepatitis__ Tuberculosis

Past Surgical History(If you have a list we can make a copy): _____________________________________________________________________________________________________Other Hospitalzations:_________________________________________________________

Are you allergic to any medications? __Yes__ NoIf yes please write the name of the Medication(s):________________________________

Current Medications: Please list all medications you are currently taking or we can make a copy of your medication list if you have it with you.__________________, ___________________, _______________, _______________,__________________, ___________________, _______________,_______________. Are you using: Oxygen_________, CPAP______________, Nebulizer_____________Do you smoke (current smoker)? Yes __No__ If so, how many packs a day?______Ex-smoker _____ # of years smoked _______ how many packs per day?______

________________Do you consume alcohol on a regular basis? __Yes __NoIf so, how much? ______Do you have any history of family diseases? _________________________________Have you ever had the flu vaccine? __Yes __NoHave you ever had the pneumonia vaccine? __Yes __No

Occupation?________________________________________________________Are you married? __Yes __NoDo you have any children? __Yes __NoDo you have pets at home? __Yes __NoHave you been exposed to dust,fumes, orasbestos? __Yes __No

Do you snore? __Yes __NoDo you stop breathing at night? __Yes __No

Do you have difficulty falling asleep? __ Yes__NoDo you have difficulty staying asleep __Yes__NoWhat time do you go to bed: ___________ and wake up ____________?Time to fall asleep? ______________ # of times you wake up at night? ____________Do you sweat at night? __Yes __NoDo you sleep walk? __Yes __NoDo you talk while sleeping? __Yes __NoDo you have nightmares/abnormal dreams?_______________Do you feel tired in the morning? __Yes __NoDo you have difficulty staying awake during the daytime? __Yes __NoDo you have restless leg symptoms? __Yes __NoDo your legs ache at night? __Yes __NoDo you feel muscle weakness while laughing or crying? __Yes __NoDo you have: Fevers______, chills___________, or night sweats________

Do you get short of breath? __Yes __No with exertion (exercise) __Yes __NoWhen did you first notice shortness of breath? __ Days __ Wks __ Months __ YrsHas the shortness of breath gotten worse over time? __Yes __NoIf so, has it gotten worse: __ slowly _____ suddenlyIf so, how much exertion does it take: (circle all that apply)a.walking slowly___ b.Walking quickly___c.Climbing up a slope/ hill___d.climbing stairsDoes anything else make you short of breath? _______________________________Do you feel shortness of breath when you first lie down at night? __Yes __NoWhen lying down do you prop your head up to breath comfortably? __Yes __NoDo you wake up at night short of breath? __Yes __NoDo your feet swell? __Yes __NoDo you wake up wheezing at night? __Yes __NoDo you cough? __Yes __NoHow long have you been coughing? ________________________________________________Does anything cause you to cough or worsen it? ______________________________________Is the cough worse at certain times of the day? _______________________________________Is the cough worse at night/does itwake you up at night? ______________________________Do you bring up sputum? __Yes __NoWhat color is your sputum: Circle one: clear, white, gray, yellow, greenOn average how much sputum do you cough up during a day? ____________________Have you ever noticed blood in your sputum? __Yes __NoDo you have pain/discomfort in your chest? __Yes __NoIf so, what area of chest: _________What type of pain: a. sharp b. dull c. stabbing d. constant e. intermittent?Does the pain shift to another part of your body? __Yes __NoIs the pain worse with exercise? __Yes __NoIs the pain worse with deep breathing? __Yes __NoDo you wheeze? __Yes __NoWhat makes you wheeze?________________________________________________________Have you ever been exposed to Tuberculosis? __Yes __NoDo you suffer from: Headaches___ Seizures___ Passing out spells____ Dizziness ____?Do you experience: Nausea______ Vomiting____ Diarrhea____ Reflux____?Do you experience: Arthritis_____ Muscle Aches_______?Did you notice: Weight loss_______ Weight Gain_______ Fatigue ____________?

Print Patient’s Name:_____________________________ Today’s Date___________________Signature of Patient:_____________________________ Date of Birth ___________________

METROPLEX PULMONARY &SLEEP CENTER, P.A.4833 Medical Center Drive, Suite 6-B


PATIENT REGISTRATION(please print)

NAME: ________________________________________DATE OF BIRTII: _____________________

ADDRESS: _________________________________________STATE: _____________ ZIP: ________

EMAIL ADDRESS: ____________________________________________________________________

HOME PHONE: _________________WORKPH #: _______________CELL PH #_________________

MARITAL STATUS: ________________ SPOUSE'S NAME: __________________________________

SS#: ___________________ EMPLOYER:_________________________________________________

SPOUSE'S EMPLOYER: ____________________________________ PHONE: ___________________

EMERGENCY CONTACT – RELATIVE/FRIEND NOT LIVING WITH YOU:_____________________________________________________________________________________(NAME) (PHONE) (RELATION SHIP)

INSURANCE INFORMATION

� PRIMARY INSURANCE COMPANY:______________________________________________

� NAME OF INSURED: __________________________________________________________

� GROUP #: ____________________ ID #: ___________________________________________

� SECONDARY/SUPPLEMENTAL INSURANCE:_____________________________________

� NAME OF INSURED: __________________________________________________________

� GROUP #: ________________________________ ID #: ______________________________

� TERTIARY/SUPPLEMENTAL INSURANCE: ______________________________________

� NAME OF INSURED:_________________________________________________________

� GROUP #: _________________________________ ID #: _____________________________

ASSIGNMENT OF INSURANCE BENEFITSI request that payment of authorized Medicare benefits be made on my behalfto MPSCfor any services furnished by the provider. I authorize any holder of medical informationaboutme to release to the Health Care Financing Administration,and its agents any information needed to determine these benefits or the benefitspayable for related services. I understand my signature requests that payment be made and authorizes release ofmedicalinformation necessary to pay the claim. If "other health insurance" is indicated in item 9 of the HCFA-1500 form, or elsewhere onotherapproved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown.

Signature of Patient or Authorized Representative: _________________________________________

METROPLEX PULMONARY & SLEEP CENTER, P.A.


AUTHORIZATION FOR RELEASEOF MEDICAL INFORMATION

TODAY'S DATE

PATIENT NAME IN FULL Male _____________

Female___________

DATE OF BIRTH SOCIAL SECURITY NUMBER

STREET ADDRESS, STATE, ZIP CODE TELEPHONE NUMBER

I hereby authorize MPSC,PA.("Facility") to RELEASE ______ or OBTAIN ______ (Please check appropriate box)information and copies of records pertaining to my medical care and treatment.

I request my medical records___ 1 Year ___ 2 Years ___ Entire Chart ___ Substance/alcohol screen results

RELEASE TO A MEDICAL FACILITY/HOSPITAL/FAMILY MEMBER OR FRIEND

OBTAIN FROM A MEDICAL FACILITY/HOSPITAL

THE INFORMATION AUTHORIZED FOR RELEASE MAY INCLUDE INFORMATION WHICH MAY INDICATE THE PRESENCE OF A COMMUNICABLE OR NONCOMMUNICABLE DISEASE, OR RELATE TO MENTAL HEALTH, OR DRUG, SUBSTANCE OR ALCOHOL ABUSE. I understand that if I am requesting records / information for release to me or patient representative:

laws may prevent certain records being released to the patientin certain situations, records denied for release to the patient may allow patient to request and obtain a review of the denial .Drug/Alcohol Abuse Treatment Records: This category of medical information/records is protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules prohibit anyone receiving this information or records from making further release unless further release is expressly permitted by the written authorization of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2, A general authorization for the release of medical or other information is not sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

This Authorization:will expire in 12months orJanuary 1st of each year.may be revoked in writing care of the Medical Records Custodian, according to the Facility's Notice of Privacy Practices, but priordisclosures will not be affectedis not required for obtaining treatment or reimbursement for treatment, unless the sale purpose of this Authorization is todetermine payment of a claim for benefitsis required for employment-related substance/alcohol screening

WARNING: We have no control over any information and records released to any person, firm or agency under thisAuthorization and it is therefore possible that a release of this information or records may occur by such party.Release: I release MPSC, PA, its employees and agents from any liability in connection with the use or disclosure of theinformation and records released to any party pursuant to this Authorization.

PATIENT· SIGNATURE DATE TIME

WITNESS· SIGNATURE DATE TIME

PERSON AUTHORIZED TO SIGN FOR PATIENT· SIGNATURE DATE TIME

REASON PATIENT UNABLE TO SIGN RELATIONSHIP TO PATIENT

PHYSICIAN / CLINICIAN AFPROVAL ·IF APPROPRIATE ___ Approve___ Decline

GIVEN TO ·INITIALS DATE

4833 Medical Center Drive, Suite 6-B

METROPLEX PULMONARY &SLEEP CENTER, P.A.


NOTICE OF PRIVACY PRACTICES

In our effort to comply with the health information act, HIPAA, we need to be certain that we guard your privacy.

USES AND DISCLOSUREOF PROTECTED HEALTH INFORMATION

Treatment: We may use or disclose your health informationto a physician or other healthcare provider providing treatment to you or your family and friends you approve.MPSC, P.A reserves the right to change or modify the privacy practices outlined in the Notice of Privacy Practices brochure.

Payment: We may use and disclose your health information to obtain payment for services we provide to you.

Healthcare operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization: You also have the right to request restrictions on disclosure of PHI (Personal Health Information) or alternative means of communication to ensure privacy.

Marketing Health Related Services: We will not use your health information for marketing communications without your written authorization.

Required by Law:If requiredwe may use or disclose your health information to law or national security services.

Abuse and Neglect: We may use or disclose your health information to appropriate authorities when we suspect abuse or neglect of early and unnecessary controlled substances’ refills.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders such as voicemail messages, postcards or letter.

Policy regarding Social Security Number:It is the possible of the office to obtain social security numbers for all patients. If you are unwilling to provide such information then our office will refuse to file to your insurance and the entire balance of your visit will be your responsibility. Our office will be happy to give you a detailed receipt so that you may file it on your behalf to your health insurance company.

SIGNATURE:I have reviewed this consent form, acknowledge receipt of the brochure entitled "Notice of Privacy Practices", and give my permission to MPSC, P.A to use and disclose my health information in accordance with this consent and the notice provided.

Patient's name (Print) Date of Birth SS#

___________________________________________________________________________________

Signature of Patient orRepresentative __________________________________ Relationship _________________________



EPWORTH SLEEPINESS SCALE

Patient Name: ______________________________________________ Date: ______________

In contrast to just feeling tired, how likely are you to doze off or fall asleep in the following situations? (Even if you have not done some of these things recently, try to work out how they would affect you.) Use the following scale to choose the most appropriate number for each situation:

0 - Would never doze1 - Slight chance of dozing2 - Moderate chance of dozing3 - High chance of dozing

Situation Chance of Dozing

Sitting and reading _______________

Watching TV _______________

Sitting inactive in a public place (i.e. theater) _______________

As a passenger in a car for a hour without a break _______________

Lying down to rest in the afternoon _______________

Sitting and talking to someone _______________

Sitting quietly after lunch without alcohol _______________

In a car, while stopped for a few minutes in traffic _______________

TOTAL SCORE: _______________

-A score less than 10 suggest that an individual is not suffering from excessive daytimesleepiness.-A total score of 10 or more suggests that you need a detailed evaluation by a physician to determine your excessive daytime sleepiness.

The Epworth Sleepiness Scale cannot be used to indicate any diagnosis. However, a score of 10 or more must be discussed by your Sleep Medicine Doctor to treat sleep disorder. An underlying medical condition for excessive daytime sleepiness can be easilytreated by your physician.

METROPLEX PULMONARY & SLEEP CENTER, P.A.


Based on past occurrences, the following services might not be paid by your insurance. By signing this statement you are agreeing to pay for these services yourself, even if those are determined by your insurance not to be “medically necessary.”

PFT, Labs (orders sent out), CPAP Supplies and Spirometry.

Please initial here:______________________

Consent for Treatment, missed follow up appointments and returned checks:

I hereby give authorization to the physician and medical staff of Dr. Shahrukh Kureishy M.Dto provide medical treatment and care. I understand that no guarantees have been made with regards to treatment success and that there may be complications associated with the condition orwith its proposed treatment.

I understand that failure to appear on scheduled follow up appointment may result in a delay in the diagnosis and treatment of a potentially serious condition. This office will call in advance to remind the patients of their upcoming appointment and will try to reschedule if the appointment cannot be kept (given 24 hours’ notice.) However, this office will not be held responsible for complications arising from missed appointments due to the patient’s noncompliance. We reserve the right to charge $25 for missed appointment. A $25 fee will also be assessed for all checks returned unpaid. Payment is expected at the time of service unless prior arrangements have been made.

Signature of Patient/Responsible Person: ____________________________________________

Patient’s Printed Name: _________________________________________________________

Date: _________________




It is necessary for our office to enact the following policies effective January 2004 due to the increase in high deductibles, co-insurance portions, co-payments, increase in insurance companies’ pending claims and withholding payments. Please feel free to ask for clarification if necessary.

We ask for your insurance information when we schedule your first appointment, and we make every effort to verify your benefits for procedures that are common in our practice. While we do our best to verify that our doctors are contracted and in network with your insurance plan, it is ultimately your responsibility that this is the case. Based upon information provided to us by your insurance company we will expect payment according to the benefits quoted. At your visit we will expect payment of the full amount of your copayment, co-insurance or deductible before seeing the doctor. We will then file your insurance claim with your insurance company for that visit. When they process your claim, they will mail to you and us an explanation of benefits. When we receive your EOB, we will adjust any contracted discounts or over payments off of your account and we will bill or reimburse you or your insurance company. However, any outstanding balances from your prior visits will also be indicated on your statement that must be paid before your next appointment. Payments for any outstanding balance will be due and payable upon receipt of the statement. If you are unable to portion of your medical bill, please ask to speak to our billing representative to make prior payment arrangement.

Many insurance plans have a requirement that patients must provide additional information to them before they will pay your claim. When this is the case, your insurance company will inform us that they have “pended” your claim for additional information. If that happens, the full balance due on your visit becomes your responsibility to pay. Once an insurance company “pends” a claim, there is nothing that our office can do to get the claim paid. It is completelyyour responsibility to contact your insurance company to provide them the needed information so your insurance company pays the claim within 30 days. Additionally, if your insurance plan, group, policy number changes, you must notify us at the time of service. Failure to provide us with current valid insurance information will result in the entire balance becoming your responsibility. This is because health care providers have a certain amount of time in which to file your insurance claim. Also, visits that have been filed in a timely fashion and go unpaid by your insurance company for 60 days will become your responsibility.Please remember that our office files to your insurance as a courtesy to you and is legally required to do so.It is important to remember that your insurance policy is a contract between you and the insurance company. We will do everything possible to assist you in getting your claim paid.

I, _______________________________, do hereby read and understand the above the financial policies. I understand that I’m financially responsible for all remaining medical fees that incurred during my treatment after my insurance pays.

Signature: ____________________________________________Printed Name: ________________________________________________ Date: ____________


Documents

METROPLEX PULMONARY SLEEP CENTER, P.A. …mpsleepcenter.com/PDF_Files/new_patient_forms.pdfMETROPLEX PULMONARY &SLEEP CENTER, P.A. 4833 Medical Center Drive, Suite 6-B McKinney, Texas