New Patient Form – Pulmonary Practice

(407) 321-8230(407) 321-0388

(386) 917-0333(386) 917-0335

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.

Printed Name of Patient or Legal Representative:	Date:
Date of Birth:
Patient or Legal Representative Signature:	Date:
Relationship of Person signing if not Patient:	Date:

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

Patient’s Last Name

First

Date of Birthday

Age

Preferred Language

Gender
MF

Social Security #

Ethnicity Hispanic/LatinoNon HispanicRefuse To Respond

Address

City

State

Zip Code

Home Phone #

Cell Phone #

Work Phone #

Chose Clinic Because / Referred to Clinic by

Other Family Member Seen Here

3. Medical Information

Primary Care Doctor	Address	Phone #
Pharmacy Name	Address	Phone #
Lab Name	Address	Phone #
Imaging Center	Address	Phone #

Are you allergic to any medications?
YesNo

Are you allergic to Penicillin?
YesNo

Please list all medicine allergies:	1	2	3
List All medications you take including dosage (include any over the counter medications/vitamins):
1	2	3	4
5	6	7	8

4. EMERGENCY CONTACT

Name of Local Friend or Relative

Relationship to Patient

Home Phone #

Alternate Phone #

5. ADVANCED CARE PLANNING – Patients age 65 years and older only

I have an advanced care plan/living will and my Surrogate Desicion Maker’s Name is stated below.I have an advanced care plan/living will but I do not wish or i am unable to name my Surrogate Decision Maker.I do not have an advanced care plane/living will but I would like information.
My Surrogate Decision Maker’s Name	Phone #


Signature of Patient or Patient Representative	Date

Printed Name of Patient or Patient Representative	Relationship to Patient

Intake Form (Page 1)

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

PATIENT INFORMATION

Name

DOB

FAMILY HISTORY

Unobtainable/Unknown (Adopted)No Significant HistoryEarly Deaths

(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

Name

DOB

Today’s Date

SOCIAL HISTORY

List ALL OCCUPATIONS including MILITARY HISTORY, from current occupation to previous:

Marital Status (check one)
SingleMarriedDivorcedWidowedSeparatedEngaged

Employment Status (check one)
Full-timePart-timeUnemployedRetiredStudent

Occupation (If retired, write “Retired”)

Employer

Employer Phone #

Smoking History / Exposure: Do you smoke:
Cigarettes?Cigars?Pipe?E-Cigs / Vaping?

If you do not currently smoke, have you ever smoked?
YesNowhen did you quit?

How much per day? For how long? (years)

Check all that apply:
Wish to stop smokingRecently stopped smokingUnsuccessful attempt(s) to stop smoking

Exposure to second-hand smoke?
YesNo

Do you use the following (check all that apply):

Alcohol Caffeine

Drug Use, Type: For how long? (years)

Pet Exposure: Exposure to animals triggers a reaction?
YesNo

I have…had recent contact with pets or other animalsAnimals living in my homeBirdsCatsDogs How many? How many?

PAST MEDICAL HISTORY

Have you ever been diagnosed as having any of the following illnesses (check all that apply):

Allergic RhinitisAlpha 1 Antitrypsin DeficiencyAnemiaAnxiety Disorder Arthritis: Type:AsthmaBlood ClotsBronchitisCAD	CancerType: COPDCHFCVA (Stroke)DepressionDiabetesEmphysemaHay FeverHeart Attack	Heart DiseaseHigh Blood PressureLow Blood PressureHIV InfectionHigh CholesterolHyperthyroidismHypothyroidismJaundiceKidney Stones	Liver DiseaseLung CancerLung Mass/NoduleMental IllnessNarcolepsyPancreatitisPneumoniaPVDKidney Disorder/Failure	Restless LegsRestrictive Lung DiseaseRheumatic FeverSarcoidosisSeizure DisorderSinusitisSleep ApneaTuberculosisWhooping Cough
Other
Previous Hospitalizations:
Your major problem at this time:

ADVANCED SLEEP DISORDER CENTER

PULMONARY PRACTICE ASSOCIATES

“Better Sleep, Better Health”

CPAP CLINIC FOLLOW-UP REPORT

Name:

DOB:

BMI:

Neck Circumference:

(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?
YesNo

If yes, how? (check all that apply)

I have lost weightI have more energyI socialize moreMy overall health is better/feel better

My overall health is better/feel better

Comments:

ROS – Subsequent Appointment

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

PATIENT INFORMATION
Name:	DOB:	Today’s Date :

Height:

Usual Weight:

Present Weight:

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

Are you here for or do you have a history of Asthma?
YesNo

Are you here for Sleep Apnea / Sleep Problems? YesNo

Current Smoker?

Yes

YesNoNever Smoked
. 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?
YesNo
If Yes, please list changes
on back of this page.

VACCINATION INFORMATION

Have you received your FLU vaccine this year?
YesNoRefused

If yes, date

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)

Patient Name:

Date:

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)

TOTAL SCORE:

Daytime asthma symptoms occur…

Most daysFew Day2 or 3 time a Weekonce a weekNot at all

Nighttime asthma symptoms…

disturb sleepcause night walkingdisturb sleep weeklydisturb sleep frequently1-2 times a monthnever disturb sleep

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

b.
all past, present, and future periods. all past, present, and future periods.

3. Extent of Authorization

a.
I authorize the release of my complete health record (including records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse).

b.
I authorize the release of my complete health record with the exception of the following information:Mental health recordsCommunicable diseases (including HIV and AIDS)Alcohol/drug abuse treatmentOther (please specify):-

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.

Signature of patient or personal representative

Printed name of patient or personal representative and his or her relationship to patient

Date

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.

ROS – Subsequent Appointment

Asthma Assesment Tool

ABOUT US

INFORMATION

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