Complete Sleep Solutions

Patient Demographics :

Name :

DOB :

Sex :

Height :

Weight :

Neck Circumference :

Ordering Physician/Primary Care Physician :

Do you have a history of?

Essential HTN	Yes No
Mood Disorder (Anxiety/Depression)	Yes No
Coronary Artery Disease	Yes No
History of Stroke	Yes No
Atrial Fibrillation	Yes No
Type 2 Diabetes Mellitus	Yes No
Congestive Heart Failure	Yes No
COPD	Yes No
Obesity Hypoventilation syndrome	Yes No
Neuromuscular Disorders	Yes No
Chronic Opioid use	Yes No

STOP-Bang Questionaire

Please answer the following question by checking "Yes" or "No" for eah one.

Snoring (Do you snore loudly?)	Yes No
Tiredness (Do you often feel tired, fatigued, or sleepy during the daytime?)	Yes No
Observed Apnea (Has anyone observed that you stop breathing, or choke or gasp during your sleep?)	Yes No
High Blood Pressure (Do you have or are you being treated for high blood pressure?)	Yes No
BMI (Is your body mass index more than 35 kg per m²)	Yes No
Age (Are you older than 50 years?)	Yes No
Neck Circumference (Is your neck circumference greater than 40 cm [15.75 inches]?)	Yes No
Gender (Are you male?)	Yes No

Score 1 point for each positive response.

Scoring interpretation : 0 to 2 = low risk, 3 or 4 = intermediate risk, >= 5 = high risk

Under gender, I want you to put -- "Are you male, or post-menopausal (for females)?"

Epworth Sleepiness Questionaire For a Medicare subsidised sleep study a patient must score 8 or more.

How Lkely are you to doze off in the following situations?	Slight Chance	Moderate Chance	High Chance
Sitting and Reading	1	2	3
Watching Television	1	2	3
Sitting inactive, in a public space	1	2	3
Lying down to rest in the afternoon when circumstance permit	1	2	3
Sitting and talking to someone	1	2	3
Sitting quitely after a lunch without alcohol	1	2	3
As a passenger in a car for an hour without a break	1	2	3
In a car, while stopped for a few minutes in traffic	1	2	3

I have personally completed these questionnaires. By signing this agreement, you acknowledge that you have read, understand, and agree to the terms and conditions of the Patient Authorization form on the next page/below.

Date :

Patient Phone Number :

Equipment Loan

Complete Sleep Solutions is loaning you sensitive medical equipment to use overnight in your home, for screening, detection or treatment of sleep breathing abnormalities and sleep apnea. This equipment must be treated with care to maintain its accuracy and usefulness. Please avoid all forceful impacts and excessive heat or cold. Do not expose the equipment to chemicals, fumes or smoke (especially tobacco smoke), water or other liquids.

Your signature on this page signifies that you are willing to take full responsibility for proper usage, care and prompt return of the equipment. Any loss or damage to the loaned equipment may result in charges equal to the replacement price for the equipment.

You may be asked to leave a security deposit on your credit card. No charges to your credit card account will be made as long as the equipment is returned within the time frame noted below and it is deemed to be undamaged. Failure to return the equipment on or before the loan period end date, designated below, will result in a $50 per day fee. All information associated with your credit card account will remain strictly confidential.

Equipment Loaned :

Loan Period Start :

Loan Period End :

I, , have read and understand the above information regarding the loan of medical equipment. I have been instructed on the proper care and operation of the equipment and understand those instructions.

I understand my obligation to return the equipment, in undamaged condition within the above designated loan period, and acknowledge that I will be assessed the current market replacement price for loss or damage to the equipment or a late fee for delayed return. I further understand that all personal, medical and financial information attained during the use of the equipment will remain strictly confidential.

Patient Name :

Date :

Registration
(Please Print)

Talha Memon M.D
39755 Date St Ste. 101
Murrieta, CA 92563

Tel : (951) 698 - 6629
Fax : (951) 698 - 8732

Patient (Last, First, MI) :

Date :

Cell Phone :

Home Phone :

Mailing Address :

City :

ZIP :

Sex :

Male

Female

Birthdate :

Email Address :

Medical Insurance :

ID# :

Group# :

SSN :

Spouse's SSN (if used for billing) :

Secondary Medical Insurance :

ID# :

Group# :

Please list people we may discuss your Medical/Financial Record with, how they are related to you, and their Contact Information.

Insurance Assignment and Release

I Certify that I have insurance coverage with

and assign directly to Dr. Talha Memon all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance.

I authorize the use of my signature on all insurance submissions. the above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below. Medicare Authorization I request that payment of authorized Medicare benefits be made either to me or on my behalf to Dr. Talha DBA Complete Sleep Solutions for any services furnished to me by that provider. To the extent permitted by law, I authorize any holder of medical or other information about me to release to the Centers for Medicare and Medicaid Services and their agents any information needed to determine these benefits or benefits for related services.

Signature :

Print Name :

Date :

Acknowledgement of Receipt of Notice of Privacy Practices

I hereby acknowledge that I understand and/or have received and/or been offered a copy of this medical practice's Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be posted in the reception area, and that i will be offered a copy of any amended Notice of Privacy Practices at each appointment. (Signing below means we will not release your medical records to anyone without your written consent)

Signature :

Date :

Print Name :

If not signed by patient, please indicate relation :

Insurance Card Front :

Insurance Card Back :

Driving Licence :

By electronically signing the Agreement, Patient consents to submitting this form in electronic form. Patient acknowledges that his/her electronic signature will have the same legal force and effect as a handwritten signature. Patient’s electronic signature, including date and time of signing will be stored electronically for Complete Sleep Solutions records.

HSAT Form

Patient Demographics :

Do you have a history of?

STOP-Bang Questionaire

Epworth Sleepiness Questionaire For a Medicare subsidised sleep study a patient must score 8 or more.

Equipment Loan

Acknowledgement of Receipt of Notice of Privacy Practices

We see patients of all ages, including children as young as age 2.