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* 1. Please enter your first and last name:

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* 2. TELEMEDICINE CONSENT: I have read and agree to the following: 

1. I understand that my health care provider wishes me to engage in a telemedicine consultation.
2. My health care provider has explained to me how the video conferencing technology will be used to affect such a consultation will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider.
3. I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties.  I understand that my health care provider or I can discontinue the telemedicine consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
4. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes.  Others may also be present during the consultation other than my health care provider and consulting health care provider in order to operate the video equipment.  The above mentioned people will all maintain confidentiality of the information obtained.  I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non‐medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time.
5. I have had the alternatives to a telemedicine consultation explained to me, and in choosing to participate in a telemedicine consultation.  I understand that some parts of the exam involving physical tests may be conducted by individuals at my location at the direction of the consulting health care provider.
6. In an emergent consultation, I understand that the responsibility of the telemedicine consulting specialist is to advise my local practitioner and that the specialist’s responsibility will conclude upon the termination of the video conference connection.
7. I understand that billing will occur from both my practitioner and, if applicable, as a facility fee from the site from which I am presented.
8. I have had a direct conversation with my doctor, during which I had the opportunity to ask questions in regard to this procedure.  My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.
By signing this form, I certify:
  • That I have read or had this form read and/or had this form explained to me
  • That I fully understand its contents including the risks and benefits of the procedure(s).
  • That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

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* 3. FINANCIAL POLICY. I have read and agree to the following:

1. As a courtesy to you our office will bill the fees for our services to your insurance plan provided that we participate with your health insurance plan and the service or procedure is covered under your plan. You must provide a copy of your most current health insurance card and a valid government issued photo ID at the time of the appointment for purposes of plan membership verification. You are responsible for the payment of any copayments the time of your visit. We are legally required to collect these with no exceptions. If your insurance requires you to meet an annual deductible before your healthcare is covered, you will be required to pay for our services if you have not met your deductible. If your insurance carrier requires you to have a referral to be seen in our office, you must provide a referral or you will not be seen. In the event your health plan determines that a visit or service we already provided is not covered, declines payment for visits and services, or fails to pay after 30 days from the date of claim submission, you will be responsible for payment in full.
2. If you have health insurance coverage with a plan we do not participate with, you will be required to pay for all services and procedures in full at the time of visit. We can help prepare a statement for you to attach to your insurance claim form for payment processing. The insurance carrier should send their payment directly to you.
3. If you do not have health insurance, you will be responsible for payment in full for the visit, services, and procedures at the time of visit.
4. We accept Visa, MasterCard, and American Express. We do not accept checks or cash.
5. It is our policy to require all patients to provide credit card information before the visit. Your credit card information will be held securely by the credit card company. Once your health insurance company has paid their portion and notified us of your share, if any, and/or you incur any additional unpaid balance on your account, we will charge the remaining balance to your credit card and then send a copy of the charges to you. For specific information relating to portion of the balance, please check the Explanation of Benefits that your insurance company is required to send you. Only your insurance company is responsible for determining your portion of the balance on the Explanation of Benefits form. You will be required to sign an updated Payment Security Authorization if your credit card information changes or expires. We will send your account to collections if we have not received full payment after 60 days of your last visit. APPOINTMENT CANCELLATION AND NO-SHOW FEES We charge a $150.00 fee for appointments that are not cancelled 48 business hours in advance (i.e. for Monday appointments, you must cancel by the appropriate time the preceding Thursday.) If you are more than 5 minutes late for your appointment, we cannot guarantee that appointment and may need to reschedule you if there are other patients waiting. COLLECTION FEES You will be responsible for all legal and court fees as well as an additional fee of $40.00 if your account falls into arrears and requires submission to our collection agency for collection. I have read, understood, and acknowledge the financial policies of the practice and I agree to be bound by its terms and conditions.

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* 4. INSURANCE PAYMENT ASSIGNMENT AND RELEASE. I have read and agree to the following:
All Insurance Patients: I request payment of authorized insurance benefits be made on my behalf directly to Jordan C. Stern, MD, PC. As the responsible party, I agree that I will be responsible for all charges incurred, including those amounts not paid by my insurance company, and in the event the charges made do not meet their reasonable and customary charges, for all services rendered to me and my dependents. I authorize any holder of medical information about me to release any information needed to determine these benefits payable for related services. I authorize the use of this signature on all my insurance submissions whether manual or electronic. I authorize a copy of this document to be used in place of the original. I understand I will be charged for, and hereby agree to pay all costs and expenses incurred in collecting any past due fees and interest allowed by law all without relief from valuation and appraisement laws.

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* 5. What is your height in feet and inches? For example, if you are 5 feet and 4 inches, write 5'4".

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* 6. What is your current weight in pounds?

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* 7. How many hours do you sleep each night?

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* 8. Do you sometimes wake up gasping for air, short of breath, or gagging?

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* 9. Do you snore?

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* 10. Do you feel rested in the morning?

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* 11. Night-time awakenings?

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* 12. Morning headaches?

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* 13. Do you suffer from memory and/or concentration problems?

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* 14. Do you complain of lack of sexual interest or decreased libido, impotence, erectile dysfunction?

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* 15. Do you nap, and if so how often?

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* 16. Blood pressure control:

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* 17. Daytime fatigue or sleepiness?

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* 18. What is your caffeine intake?

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* 19. INSTRUCTIONS: The Epworth Sleepiness Scale is widely used by health insurance companies to determine whether they will cover sleep apnea treatments.  The average score in the US is around 9.  A score of 11 or more indicates excessive sleepiness, and an indication for insurance companies to cover the cost of testing and treatment.  The test was developed in the Mid-West, where most subjects and patients drive; not the case in a big city like NY.

Use the following scale to choose the most appropriate number of each situation: "chance of dozing", think of this as "sleepiness". Note that there are 2 questions about driving, if you do not drive, think of how sleepy you are in a bus or subway ... do not just chose "0" as the score. Also note this is "chance of dozing", not actually falling asleep.

0 = no chance of dozing
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing

  0 1 2 3
Sitting and reading
Watching TV
Sitting inactive in public space (theater or meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon (when possible)
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic

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* 20. Please carefully answer "Yes" or "No" to all questions below. If you have conditions that do not appear in this list you will be able to add them to your medical record at the time of your visit or by sending a message to our staff.

  Yes No
Depression
Sleep disorder, chronic
Acid reflux
Cardiac arrhythmia
Asthma
Atrial fibrillation
Attention deficit disorder
Cancer
High blood pressure
Sleep apnea
Stroke
Heart disease
Thyroid disease

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* 21. Diabetes or pre-diabetes

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* 22. Please select "Yes" or "No" to the symptoms related to your health that apply to you.

  Yes No
Chest pain
Irregular heartbeat
Shortness of breath
Weakness
Weight gain
Heartburn
Frequent urination
Muscle aches
Memory loss
Headache
Blurred vision
Hot flashes

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* 23. Please list known medical conditions on father's side of family.

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* 24. Please list known medical conditions on mother's side of family.

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* 25. Describe your sleep problem in detail:

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* 26. Please enter all prescription medications and dosage

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* 27. Upload front of your health insurance card

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
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* 28. Upload Back of your health  insurance card

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
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* 29. Upload the front of your driver's license

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
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* 30. If you were referred by a health care provider please indicate her or his name below; if not please type "no"

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* 31. Please enter your current pharmacy name, address, and phone number if known

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