Please use this form for general information purposes only. DO NOT send personal health information through this form. Specific patient care must be addressed during your appointment.

Name*

Date of Birth*

Phone*

Who is your Primary Insurance Carrier?

Upload Insurance Card Front & Back

Drop files here or

Accepted file types: jpg, gif, tif, png, pdf, Max. file size: 256 MB, Max. files: 4.

Member ID*

HMO, PPO, EPO?*

HMO
PPO
EPO

Email*

Preferred Date

Preferred Time

Reason for Visit*

Evaluate for Sleep Apnea
Evaluate for Insomnia
Evaluate for Restless Legs or Leg Kicking During Sleep
Evaluate for Movements During Sleep
Evaluate for Narcolepsy
Go to Bed too early e.g., before 8pm or Go to bed too late after Midnight
Excessive Sleepiness During the Day
Other

Consent*

I agree to the privacy policy.

CONSENT TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION
1. I give this practice/clinic my consent: to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies, and for health care operations like quality reviews.
2. I have been informed: that I may review the practice/clinic Notice of Privacy Practices (for a more complete description of uses and disclosures) before signing this consent.
3. I understand that this practice/clinic: has the right to change its privacy practices and that I may obtain any revised notices at the practice/clinic.
4. I understand that I have the right to request a restriction: on how my protected health information is used. However, I also understand that the practice/clinic is not required to agree to the request. If the practice/clinic agrees to my requested restriction, they must follow the restriction(s).
5. I also understand that I may revoke this consent for the use or disclosure of my protected health information, at any time, by making a request in writing, except for information already used or disclosed.

Name

This field is for validation purposes and should be left unchanged.

Barlite Blvd. Office