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.Please complete the following form to request an appointment. Please also note that availability will vary depending on your request. Your appointment will be confirmed by phone by a member of our staff. Thank you!Name* Date of Birth* MM slash DD slash YYYY Phone* Who is your Primary Health Insurance Carrier?* Aetna Amerigroup Blue Cross / Blue Shield Cigna Humana Medicaid Medicare Superior Healthplan Tricare TriWest Upload Insurance Card Front & Back Drop files here or Select files Max. file size: 256 MB. Member ID* HMO, PPO, EPO?* HMO PPO EPO Email* Preferred Date MM slash DD slash YYYY Preferred TimeMorningAfternoonReason 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.CAPTCHANameThis field is for validation purposes and should be left unchanged.
