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.
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.
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.
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.
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
5. ADVANCED CARE PLANNING – Patients age 65 years and older only
Intake Form (Page 1)
Directions: All sections must be completed. Write “N/A” if not applicable
Intake Form (Page 2)
Directions: All sections must be completed. Write “N/A” if not applicable
ADVANCED SLEEP DISORDER CENTER
PULMONARY PRACTICE ASSOCIATES
“Better Sleep, Better Health”
CPAP CLINIC FOLLOW-UP REPORT
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.
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?
ROS – Subsequent Appointment
Directions: All sections must be completed. Write “ N/A” if not applicable
SYMPTOMS: Are you having any of these symptoms (check all that apply):
Are you here for or do you have a history of Asthma?
Are you here for Sleep Apnea / Sleep Problems?
Yes No Never 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?
If Yes, please list changes
on back of this page.
Have you received your FLU vaccine this year?
Yes No Refused
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)
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?
2. During the past 4 weeks, how often have you had shortness of breath?