General Consent and Service Terms
General Consent for Treatment
I agree to allow Pulmonary Practice Associates (Pulmonary Practice Associates) to provide all health care services to me that are routine or otherwise deemed necessary. I understand I have the right to refuse consent to any proposed procedure or treatment at any time prior to receiving it. I understand that any treatment involving material risks will be explained to me and that I will have the opportunity to ask questions about the associated risks, alternatives and prognosis before allowing the treatment to be performed. I agree that no guarantees have been given to me as to the outcome of any treatment. I agree my picture can be taken to identify me.
General Sharing Health Information
I agree to Pulmonary Practice Associates using and sharing all my health information, including but not limited to Highly
Confidential Information (see definition below), for payment, my continued treatment, and healthcare operations. This includes
sharing my information with the following:
All physicians and other medical service
providers associated with my treatment,
as well as other physicians who are
participating in integrated physician plan
networks or Health Information
Exchanges.
Business partners of Pulmonary Practice Associates, its affiliates, and Physicians, who provide administrative, operational, financial, legal and technical support services. All insurance Payer(s) and healthcare plans responsible for paying or determining if I am eligible for payment for my treatment.
Substance, Drug, and Alcohol Abuse Authorization
I authorize and have initialed below for Pulmonary Practice Associates to release, should any exist, all my substance abuse and drug and alcohol abuse health information to any affiliate for my treatment, payment for my treatment, and the health care operations of Pulmonary Practice Associates. I understand this authorization may be cancelled at any time, unless Pulmonary Practice Associates have already acted and relied on it. If not previously revoked, I understand this authorization is effective until I am deceased.
Initial here:
Insurance Assignment and Payment
I permanently assign my third-party payer benefits payable directly to Pulmonary Practice Associates. I understand and agree that regardless of my insurance status, I am ultimately responsible for the balance on my account for any services rendered.
I understand and agree that payment of my out-of-pocket portion for all elective services must be paid 10 days prior to receiving the service or the service will be cancelled and then rescheduled when such payment is received. If I do not pay for all my services and an attorney or collection agency asks me to pay, I agree to pay the reasonable attorney’s fees and/or collection expenses in addition to paying for the cost of all my services.
I authorize Pulmonary Practice Associates to file an appeal on my behalf for any denial of payment and/or adverse benefit determination related to services and care provided. If my health insurance or third-party payer will not direct payment to Pulmonary Practice Associates, I agree to forward Pulmonary Practice Associates all health insurance payments which I receive for the services rendered by Pulmonary Practice Associates.
Unless otherwise designated by the payer, I understand Pulmonary Practice Associates posts all payments received to the oldest balances first, except for copays, drugs and supplies. I give permission to apply and credit balances to offset amounts due to Pulmonary Practice Associates where I have received services for current accounts or accounts I have not paid yet.
I authorize the use of my signature below on all insurance submissions. I may at any time in the future cancel this authorization in writing.
Medicare Assignment of Benefits
I certify that the information given by me in applying for payment under Title XVII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carries any information needed for this or a relate Medicare Claim. I permit a copy of this authorization to be used in place of the original. I request that payment of the authorized benefits be made on my behalf. I assign the benefits payable for physician services to the physician or organization furnishing the services or authorize such physician or organization to submit a claim to Medicare for payment to me.
Self-Pay Request
If I do not want my insurance company(ies) to receive health care information about this treatment I understand I will need to inform the staff and complete the Request to Restrict Use and Disclosure of Protected Health Information form.
Communication
Messages and Mail:

I understand you may communicate with me through US Mail, electronic mail, telephone or voice mail messages, to remind me about my appointments, treatment follow-up or to tell me about new services that are available. I understand that I must tell you if I do not want you to communicate with me like this.

Sharing PHI with family and friends:

I understand you will share my PHI with the family members, friends, or other individuals who are present with me unless I tell you otherwise.

Wireless Calls and Texting:

I agree and have initialed below for Pulmonary Practice Associates to use an automated telephone dialing system, and texting, to contact the cellular telephone number(s) that I provided for appointment, treatment, and payment purposes.

Initial here:
Signatures
BY SIGNING BELOW, I AM AGREEING TO THE PERMISSIONS, AGREEMENTS, AND AUTHORIZATIONS DESCRIBED IN THIS AGREEMENT. I HAVE READ THIS AGREEMENT AND HAVE BEEN ABLE TO ASK QUESTIONS. I UNDERSTAND THIS AGREEMENT IS VALID FOR ONE YEAR FROM THE DATE I SIGN IT.
 
Please review the highly confidential information as defined by your state:
Florida: Mental health, HIV/AIDS, genetic testing, venereal disease, and tuberculosis information
 
Registration Form
Patient Form
Gender
Gender
AsianBlackWhiteAmerican Indian / Alaska NativeOther
Marital Status
SingleMarriedDiscoveredWidowed
Ethnicity
 
2. INSURANCE INFORMATION (PLEASE GIVE YOUR INSURANCE CARD(S) AND A PHOTO ID TO THE RECEPTIONIST)
Is this Patient Covered Insurance?

Patient’s Relationship to Subscriber of Primary Insurance
If Not Primary Subscriber:




Patient’s Relationship to Subscriber of Secondary Insurance
If Not Primary Subscriber:



 
3. Medical Information
Are you allergic to any medications?

 
Are you allergic to Penicillin?

 
List All medications you take including dosage (include any over the counter medications/vitamins):
 
4. EMERGENCY CONTACT
 
5. ADVANCED CARE PLANNING – Patients age 65 years and older only


 
   
Signature of Patient or Patient Representative
   
 
 
Intake Form (Page 1)
Directions: All sections must be completed. Write “N/A” if not applicable
PATIENT INFORMATION


FAMILY HISTORY
(Use the following “M” = Mother, “F” = Father, “S” = Sister(s), “B” = Brother(s): Who in your family has had…
Allergies Alpha 1 Antitrypsin
Deficiency
Arthritis
Arthritis type
Asbestosis
Asthma
Cancer
Cancer type
COPD Deep Venous
Thrombosis
Heart Disease
High Blood Pressure
Pulmonary Embolism
Renal (Kidney) Disease
Sarcoidosis
Sleep Disorder
Stroke Syndrome
Thyroid Disorders
Tuberculosis
SURGICAL HISTORY
Please check any surgeries you have had and provide details (check all that apply):
General Surgery
  Date & Details
Amputation (s)
Aneurysm
Sinus
Thyroid
  Date & Details
Tonsillectomy
Uvuloplasty
Wrist
Other
Cardiovascular Surgery
AAA
CABG
Carotidr Endarterectomy
Stent
Heart Valve Replacement
Angioplasty
Pacemaker
Total # Performed
Lung Surgery
Bronchoscopy
Lung Biopsy
Thoracentesis
Lung Biopsy
Lung Surgery
Lung Surgery
Pneumonectomy
Excision of Lesion of Mediastinum
Excision Lesion of Chest Wall
Wedge Resection of Lung
 
 
Intake Form (Page 2)
Directions: All sections must be completed. Write “N/A” if not applicable
PATIENT INFORMATION



SOCIAL HISTORY

Marital Status (check one)
Employment Status (check one)
Smoking History / Exposure: Do you smoke:

   
If you do not currently smoke, have you ever smoked?
   
   
Check all that apply:
Exposure to second-hand smoke?
Do you use the following (check all that apply):
   
  
Pet Exposure: Exposure to animals triggers a reaction?
I have…
PAST MEDICAL HISTORY
Have you ever been diagnosed as having any of the following illnesses (check all that apply):


 
ADVANCED SLEEP DISORDER CENTER
at
PULMONARY PRACTICE ASSOCIATES
“Better Sleep, Better Health”
CPAP CLINIC FOLLOW-UP REPORT




(inches)
 
Rate each description according to your normal way life in recent times. Even if you have not been in some of these
situations recently, try to determine how sleepy you would have been.
Use the following scale to choose the best number for each situation:
 
0 = would never doze.
1 = would have a SLIGHTLY CHANCE of dozing.
2 = would have a MODERATE CHANCE of dozing.
3 = would have a HIGH CHANCE of dozing.
 
SITUATION:
Likelihood of falling asleep: CHANCE OF DOZING
1. During the day, after lunch, without alcohol
2. Sitting and reading
3. Watching TV
4. Sitting inactive in a public place (e.g. theater, or in a meeting)
5. Sitting as passenger in a car for an hour without a break
6. Lying down to rest in the afternoon
7. Sitting and talking to someone
8. In a car while stopped in traffic
  Total Score
Answer the question below ONLY IF you have had CPAP or BiPAP ordered:
Do you feel your treatment has improved your quality of life and health?
If yes, how? (check all that apply)

 
 
 

ROS – Subsequent Appointment

Directions: All sections must be completed. Write “ N/A” if not applicable
PATIENT INFORMATION

DOB: Today’s Date :



SYMPTOMS: Are you having any of these symptoms (check all that apply):
FeverNight SweatsChillsRashesShortness of BreathWheezingCough

Sputum: Color

Blood in SputumHeadacheSinus CongestionNasal DischargeDischage drips down throat causing coughExcessive ThirstSwollen Glands (neck)Sore ThroatDifficulty SwallowingHoarsenessChest Pain / DiscomfortPleuritic Chest PainChest TraumaFeelings of WeaknessFaintingParalysisSeizure(s)AnxietyDepression
Weight ChangeAbdominal PainNauseaVomitingDiarrhea

HeartburnCauses Awakeningwith Regurgitation

Calf TendernessLeg SwellingLimb SwellingLegs feel RestlessSnoringSleepinessFatigueSleep too muchInsomniaSleep DisturbanceMuscle AchesJoint Pain / ArthritisHearing LossFast Heart RatePalpitation

Exposure to…

AsbestosFumesSandblasting
 
Are you here for or do you have a history of Asthma?
YesNo
Are you here for Sleep Apnea / Sleep Problems? YesNo
Current Smoker?

  

. If No Longer a smoker, when did you quit? Date/Years
Any Changes in your Family, Social, Medical, or Surgical History since you last appointment?

  If Yes, please list changes
on back of this page.
 
VACCINATION INFORMATION
Have you received your FLU vaccine this year?

  

When was your last Pneumonia Shot? Date/Year   Prevnar 13 Shot? Date/Year
 

Asthma Assesment Tool

(Only Complete if you were previously diagnosed with Asthma)


1. In the past 4 weeks, how much of the time did your asthma keep you from getting as much
done as usual at work, school, or at home?
1 (All of the time)2 (Most of the time)3 (Some of the time)4 (A little of the time)5 (None of the time)
2. During the past 4 weeks, how often have you had shortness of breath?
1 (More than once a day)2 (Once a day)3 (3-6 times a week)4 (Once or twice a week)5 (Not at all)
3. During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortnes of breath, chest tightness, or pain) wake you up at night or earlier than usual in the morning?
1 (4 or more nights a week)2 (2-3 nights a week)3 (Once or twice a week)(4 Once a week)5 (Not at all)
4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication?
1 (3 or more times per day)2 (1 or 2 times per day)3 (2 or 3 times per week)4 (Once a week or less)5 (Not at all)
5. How would you rate your asthma control during the past 4 weeks?
1 (Not controlled at all)2 (Poorly controlled)3 (Somewhat controlled)4 (Well controlled)5 (Completely controlled)
 

 
Daytime asthma symptoms occur…
Nighttime asthma symptoms…
 
 
 
HIPAA Privacy Authorization Form
Authorization for Use or Disclosure of Protected Health Information
(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)
1. Authorization
I authorize (healthcare provider) to use and disclose the protected health information described below to (individual seeking the information).
 
2. Effective Period
The authorization for release of information cover the period of healthcare from:
a. to
OR
b.
all past, present, and future periods. all past, present, and future periods.
 
3. Extent of Authorization
a.
OR
b.

 
4. This medical information may be used by the person I authorize to receive this information for medical
treatment or consultation, billing or claims payment, or other purposes as I may direct.
 
5. This authorization shall be in force and effect until (date or event), at which time
this authorization expires.

 
6. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a
revocation is not effective to the extent that any person or entity has already acted in reliance on my
authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the
insurer has a legal right to contest a claim.
 
7. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on
whether I sign this authorization.
 
8. I understand that information used or disclosed pursuant to this authorization may be disclosed by the
recipient any may no longer be protected by federal or state law.
 
 
 
 

ABOUT US

When it comes to breathing disorders, our physicians and staff at Pulmonary Practice Associates understand how important it is for you to choose a qualified physician who will provide the best care possible to get you back to living a healthy and comfortable life.


1075 Town Center Dr, Orange City, FL 32763
Phone Number: (386) 917-0333
Fax Number: (386) 917-0335

749 Stirling Center Place, Lake Mary, FL 32746
Phone Number: (407) 321-8230
Fax Number: (407) 321-0388

8400 Red Bug Lake Road, Suite 2010, Oviedo, FL, 32765
Phone Number: (407) 321-8230
Fax Number: (407) 321-0388

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