TEXAS PEDIATRIC SPECIATLIES AND FAMILY SLEEP CENTER

REGISTRATION FORM – PEDIATRIC (Please Print)

Referring Physician: _ Primary Care Physician: _

Patient’s LEGAL Last name: _ _ First: Middle Initial:

Patient date of birth _ _/_ / Patient Race: ________________________Patient Ethnicity: _

Primary home street address: ____________________________________________________________________________ Apt #: _

City: State: _ Zip: Social Security#: _ ‐_ ‐ _

Primary parent email address:

Home phone ( ) _ _ Cell phone ( ) _ Employer phone ( ) _

Ok to leave a voicemail at the numbers listed? Yes/No If so, preferred # ( ) _

In case of an emergency, who should we notify: ___________________________________Phone:( ) _

Relationship to patient:__________________________________________

Is this person authorized to make medical decisions? Yes/No If not, please provide a contact that is authorized to make medical decisions:

Name: _ Relationship to patient: _ INSURANCE INFORMATION

Subscriber’s Name: _ Date of Birth: _ / /

Subscriber’s SS #: _‐ ‐_ Relationship to patient: _ Employer: _____________________________

Insurance Name: _ _ Subscriber ID #: _ _ Group #: _

Secondary Insurance: YES / NO

Subscriber’s Name: Date of Birth: _ / / Employer: _______________________________

Subscriber’s SS#: _ ‐ _‐ Relationship to patient:

Insurance Name: _ _ Subscriber ID #: _ _ Group #: _ ASSIGNMENT AND RELEASE

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Texas Medical & Sleep Specialists or my insurance company to release any information required to process my claims. _ _ Signature of Parent, Guardian or Responsible Party Date

_ _ Printed name of parent, guardian or responsible party Relationship to patient Revised‐07/22/19

Revised 9/13/18

Electronic Prescriptions

We subscribe to an electronic prescription service. Our physicians transmit e-prescriptions via a secured internet network directly to participating pharmacies. Please list your pharmacy name, address and phone number below. TMSS has the ability to download my pharmacy benefits and medication history through a secure internet network. This will allow your physician to prescribe medications covered by your health insurance plan and also prevent any medication allergies or duplicate prescriptions from being prescribed. By signing below, I give my permission for TMSS to download this information from the above pharmacy. This is an OPTIONAL service provided by TMSS. If you do not wish to participate, feel free not to sign below. **Effective October 1, 2018** All refill requests will be processed through your patient portal. Please allow 24 to 72 hours to process. You can also contact your pharmacy and your pharmacy will contact our office. We will no longer process patient phone call refill requests. If you do not have a patient portal account, please ask the receptionist for details.

Patient’s Name:

_______________________________________________________________ Name of Pharmacy:

_______________________________________________________________ Pharmacy Address:

_______________________________________________________________ Pharmacy Phone #: (_____) _____ - __________ ____________________________________ ________________

Patient or Guardian Signature Date

Revised 06/27/19

Pediatric Consent to Leave Messages/Share Information with Family/ Friends

I understand that for Texas Pediatric Specialties & Family Sleep Center (TPS &FSC) to leave detailed messages containing specific medical information on my voicemail or answering machine, I need to give my permission to TPS & FSC. Consent for Leaving Messages: I give consent to TPS & FSC to leave a message on my voicemail/answering machine about my child’s lab results. I understand that “sensitive information as noted below will be excluded. Yes No Consent for shared information with Family & Friends: The Name(s) listed below are family members or friends to whom I grant permission for my child’s health care provider and their representatives at TPS & FSC to verbally discuss their care using their best judgement and grant them permission to disclose health information that is relevant to their care. Yes No Under the HIPPA Privacy Law we are permitted, and we may make a professional judgement that certain disclosures are in your best interest even without this signature. I understand that information is limited to verbal discussions and that no paper copies of my/my child’s protected healthcare information will be provided without my signature on a release of Information Form. I understand that some information, as listed below, is considered “sensitive.” I understand that I must check the specific boxes for my provider or his/her designee to release any “sensitive” information.

Medical Conditions Mental Health/ Psychiatric disorders (including Depression) Chemical Dependency (Drug and/or alcohol abuse/treatment) Pregnancy Information

Name: Relationship: _______________________________ _______________________________ Patient’s Name (Please Print): _______________________________ DOB: ____________________ Patient or Parent\Guardian Signature: _________________________ Date: ____________________

                            CLINICAL RESEARCH INTEREST FORM               

Road Runner Research “Dedicated to Finding Solutions”

1.2.19 

 

Being part of a clinical research trial is a great opportunity to contribute to the constantly evolving world of medicine and participate in innovative medical treatment.  Your participation could help guide the future of medicine.  By participating you may receive: 

Free medical evaluations Free study medication Compensation for time and travel 24/7 monitoring and access to study physician

Although it is not guaranteed that you will experience benefits from participating in clinical trials, many subjects believe that there is a positive outcome due to their involvement in research studies.  

∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞ Please choose one. By selecting yes, you are NOT obligated to participate: 

  I DO NOT WISH TO BE CONSIDERED FOR RESEARCH AT THIS TIME. If no, please complete patients name, date of birth, sign & date form so we do not contact you going forward. Please note, if in the future you change your mind and would like information, we will present a new form for your completion.  

 I AM INTERESTED IN OBTAINING INFORMATION ABOUT STUDIES.  *Patient’s Name:_________________________         *Patient’s DOB:____________________  Male/Female  (circle one)  Parent/Guardian’s Name (if above person is under 18): _____________________________________________________  *Patient/Parent Phone Number: _________________________________   Best Time to contact: ___________________  Mailing address: ____________________________________________________________________________________  Patient/Parent E‐mail Address: ________________________________________________________________________   

*REQUIRED INFORMATION  

May we add you and/or your child’s information into the Road Runner Research database (information will not be provided to any additional research sites or companies) for any possible future trials/studies so that we may contact you?     Yes   No  If no, all provided information will not be added to the Road Runner Research database.  PLEASE SELECT THE CONDITIONS YOU WOULD LIKE TO RECEIVE INFORMATION (Please check all that apply):   [  ] Spasticity (Cerebral Palsy)              [  ] Narcolepsy            [  ] Major Depression  [  ] Chronic Pain      [  ] Migraines            [  ] Down Syndrome [  ] Epilepsy/Seizures      [  ] Tourette Syndrome          [  ] Bi‐Polar Disorder [  ] Autism      [  ] Fragile X Syndrome          [  ] Asthma [  ] Attention Deficit Disorder            [  ] Insomnia                                                      [  ] Allergies [  ] OTHER(S): _____________________________________________________________________________________  

 ______________________________________________         _________________________ Self (if over 18)/Parent/Guardian Signature                                                         Date 

Revised 5/9/18

Our Financial and Office Policies

Thank you for choosing Texas Pediatric Specialties and Family Sleep Center as your healthcare provider. We are committed to providing our patients with the best available medical care. Our billing department will be available to discuss our fees and policies with you if you have any questions. We ask that all responsible parties read and sign our financial and office policies and complete the patient information form prior to seeing the physician. As you read, please initial beside each topic to indicate your understanding of our policies.

_ _1. Demographic Information- Please inform the receptionist if your address, phone number, or insurance information has changed (or if you anticipate that it will be changing in the near future). ______2.Copay -All co-pays, deductibles, and/or co-insurances are due at the time of service. ______ 3. Balances- If you have balance on your account we will ask for payment. We accept cash, check, Visa and MasterCard. We allow 90 days for payment of any balances that are the responsibility of the patient. If we do not receive full payment in 90 days, the account will be referred to collections. If your account is sent to collections, you will incur ALL fees associated. We understand that temporary financial problems may affect timely payments of your balance. We encourage you to communicate any such problems to us, so that we may assist you to keep your account in good standing.

4. Insurance Verification-We verify insurance benefits as a courtesy to our patients. Not all services are a covered benefit in your medical plan. Please contact your insurance company if you have questions regarding your health care coverage. Texas Pediatric Specialties and Family Sleep Center provides services that are medically necessary in the physician’s professional opinion. If you are unsure if a procedure, immunization or injection is covered, please call your insurance company prior to receiving services. You are ultimately responsible for all charges that are not covered under your health care policy. Please remember that your insurance is a contract between you (or your employer) and the insurance company. We are not a party to that contract. _____ 5. Referrals-If your appointment requires a referral from you primary care physician, that referral will need to be on file with our office before the appointment day. Please contact your primary care physician to ensure this referral is sent to our office in time for the upcoming appointment. If you are seen without a referral on file and the insurance company does not pay, you will be responsible for all charges.

6. No Show Fee-

If you are more than 20 minutes late for your appointment, it is considered a (No-Show). A $50.00 fee will be applied.

Appointments not canceled with a 24 hour notice will be subject to a charge of $50.00. After 3 “no show” appointments we reserve the right to terminate the physician/patient

relationship. A notification will be sent to the responsible party and to the referring physician. Should the physician choose not to terminate the relationship, we reserve the right to charge a $50.00 deposit for any future appointments. This deposit can be applied to any copay, co-insurance or deductible due at time of service or the deposit will cover the cost of the no show fee.

Revised 5/9/18

_____ 7. Returned Checks-Any personal check that is returned due to insufficient funds will be subject to a $35.00 charge in addition to the amount of the check. After one instance of a returned check, all further payments will be required to be in the form of credit card, cash or money order only. 8. Medical Records-There is a $25.00 fee for the first 20 pages and $.50 thereafter for copies of medical records not requested by another physician. The patient, parent or guardian must complete an authorization to disclose health information. ___ 9.FMLA- There is a $25.00 fee to complete any FMLA paperwork. Please allow 7-10 business days for completion. 10. Prescription Refills-ALL prescription refills are transmitted via e- prescriptions via a secured internet network directly to participating pharmacies. You can have your pharmacy submit the refill request electronically or they may fax the request. We DO NOT accept calls directly from patients for refills. Please do not wait until you are out of medication to ask your pharmacy for a refill. We require 5 business days to respond to a refill request. Please note that we do not process refill requests on the weekends or holidays. The patient must have a follow-up appointment scheduled or have been seen within the last 6 months in order to have any prescriptions refilled. 11. Triplicate prescriptions (Triplicate prescriptions are for Schedule II controlled substances): All expired

Triplicate prescriptions that are not filled must be returned to our office. Triplicate prescriptions must be filled within 21 days. There is a $5 fee for each triplicate prescription that is picked-up in a timely manner and a $25 fee for expired triplicate prescriptions (i.e. not picked-up in a timely manner). Triplicate prescriptions can be mailed certified for a fee of $25.00 in addition to the regular $5.00 refill fee.

I HAVE READ AND I UNDERSTAND THE ABOVE POLICIES

/ /

Signature of patient (or responsible party) Date

Printed name of patient (or responsible party) Witness

Acknowledgement of Receipt of Notice of Privacy Practice

By signing this form, you are granting consent to Texas Pediatric Specialties and Family Sleep Center to use and disclose your protected health information for the purpose of treatment, payment and health care operations. Our Notice of Privacy Practices provides more detailed information about how we may use and disclose this protected health information. You have a legal right to review our Notice of Privacy Practice before you sign this consent and we encourage you to read it in full.

Our Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice by contacting our health information office at: 210-249-5020.

You have a right to request us to restrict how we use and disclose your protected health information for the purposes of treatment, payment or health care operations. We are not required by law to grant your request. However, if we do decide to grant your request, we are bound by our agreement.

You have the right to revoke this consent in writing, except to the extent we already have used or disclosed your protected health information in reliance on your consent.

Patient Name (Print):

Signature:

Date:

Office Use Only:

As Privacy Officer, I attempted to obtain the patient’s (or representatives) signature on this

Acknowledgement but did not because

Signature of Privacy Officer Revised 5/3/18

[Type here] Revised 06/27/19

AUTHORIZATION FOR MEDICAL TREATMENT of a MINOR

CHILD: ___________________________________ DOB: ___________________________

I _______________________________ ________________________________________ ________________________ Legal Custody/Guardian Address (Street, City, Zip Code) Phone Number declare I have legal custody and am the guardian of the child mentioned above. I give the following permission:

• To attend appointments with mentioned child at Texas Pediatric Specialties and Family Sleep Center • To receive medical information for the mentioned child • To authorize medical treatment or medical procedures for the mentioned child ____________________________________________________________________________________________________________________

____________________________________________ _______________________________________________________ _______________________________ Full Name (ID must be presented at DOS) Address (Street, City, Zip Code) Phone Number ____________________________________________ _______________________________________________________ _________________________________ Full Name (ID must be presented at DOS) Address (Street, City, Zip Code) Phone Number ____________________________________________ _______________________________________________________ _________________________________ Full Name (ID must be presented at DOS) Address (Street, City, Zip Code) Phone Number

____________________________________________ _______________________________________________________ _________________________________ Full Name (ID must be presented at DOS) Address (Street, City, Zip Code) Phone Number

Legal Guardian Signature: ___________________________________________ Legal Guardian Printed Name: ________________________________________ Date: _____________________________________________

Sleep Evaluation Questionnaire Patient Name: _______________________________________________________

Date of birth: _____/_______/_______

Directions Please answer each of the following questions by writing in or choosing the best answer. This will help us know more about your family and your child.

CHILD’S INFORMATION

What are your major concerns about your child’s sleep?

What things have you tried to help your child’s problem?

Current Daytime Symptoms

–

1. Trouble getting up in the morning a b c d e f

2. Falls asleep in school a b c d e f

3. Naps after school a b c d e f

4. Daytime sleepiness a b c d e f

5. Feels weak or loses control of his/her muscles with strong emotions

a b c d e f

6. Reports unable to move when falling asleep or upon waking a b c d e f

7. Sees frightening visual images before falling asleep or upon a b c d e f

waking

SLEEP HISTORY Weekday Sleep Schedule

Write in the amount of time your child sleeps during a 24-hour period during weekdays:

(add daytime and nighttime sleep)

_______ hours ______minutes

The child’s usual bedtime on weekday nights : __________:__________

The child’s usual wake time on weekday mornings:

__________:__________

Weekend/Vacation Sleep Schedule

Write in the amount of time your child sleeps during a 24-hour period during weekends and vacations: (add daytime and nighttime sleep)

_______ hours _______ minutes

The child’s usual bedtime on weekend/vacation nights :

__________:__________

The child’s usual wake time on weekday mornings:

__________:__________

Nap Schedule

Number of days each week child takes a nap: 0 1 2 3 4 5

6 7If child naps, write in usual nap time(S): Nap 1: _____: _____ a.m./p.m. to _____ : _____ a.m./p.m.

Nap 2: _____ : _____ a.m./p.m. to ____ : ____a.m./p.m.

General Sleep

Does the child have a regular bedtime routine? yes no

Does the child have his/her own bedroom? yes no

Does the child have his/her own bed? yes no

Is a parent present when your child falls asleep? yes no

Child usually falls asleep in... Child sleeps most of the night in... Child usually wakes in the morning in...

o own room in own bed (alone) o parents’ room in own bed oparents’ room in parents’ bed osibling’s room in own bed osibling’s room in sibling’s bed

o own room in own bed (alone) o parents’ room in own bed oparents’ room in parents’ bed osibling’s room in own bed osibling’s room in sibling’s bed

o own room in own bed (alone) o parents’ room in own bed oparents’ room in parents’ bed osibling’s room in own bed osibling’s room in sibling’s bed

Child is usually put to bed by: Mother Father Both Parents Self Others

Write in the amount of time the child spends in his/her bedroom before going to sleep: minutes

If yes, do you think this is a problem? Yes No

If yes, do you think this is a problem? Yes No

If yes, do you think this is a problem? Yes No

After nighttime awakening, child has difficulty falling back to sleep? Yes No

If yes, do you think this is a problem? Yes No

Child is difficult to awaken in the morning? Yes No If yes, do you think this is a problem? Yes No

Child is a poor sleeper? Yes No If yes, do you think this is a problem? Yes No

Current Sleep Symptoms

–

1. Difficulty breathing when asleep a b c d e f

2. Stops breathing during sleep a b c d e f

3. Snores a b c d e f

4. Restless sleep a b c d e f

5. Sweating when sleeping a b c d e f

6. Daytime sleepiness a b c d e f

7. Poor appetite a b c d e f

8. Nightmares a b c d e f

9. Sleepwalking a b c d e f

10 Sleeptalking a b c d e f

11 Screaming in his/her sleep a b c d e f

12 Kicks legs in sleep a b c d e f

13 Wakes up at night a b c d e f

14 Gets out of bed at night a b c d e f

15 Trouble staying in his/her bed a b c d e f

16 Resists going to bed at bedtime a b c d e f

17 Grinds his/her teeth a b c d e f

18 Uncomfortable feeling in his/her legs; creepy-crawly feeling a b c d e f

19 Wets bed a b c d e f

SCHOOL PERFORMANCE

CURRENT SCHOOL PERFORMANCE (if school-aged)

Your child’s grade:

Has your child ever repeated a grade? No Yes

Is your child enrolled in any special education class?

No Yes

How many school days has your child missed so far this year?

How many school days did your child miss last year?

How many school days was your child late so far this year?

How many school days was your child late last year?

Child’s grades this year: Excellent Good Average Poor Failing

Child’s grades last year: Excellent Good Average Poor

Failing

FAMILY’S INFORMATION

FAMILY SLEEP HISTORY Does anyone in the family have a sleep disorder?

If yes, mark the disorder(s):

Yes No

Insomnia Mother Father Brother/sister Grandparent

Snoring Mother Father Brother/sister Grandparent

Sleep apnea Mother Father Brother/sister Grandparent

Restless legs syndrome Mother Father Brother/sister Grandparent

Periodic limb movement disorder Mother Father Brother/sister Grandparent

Sleepwalking/sleep terrors Mother Father Brother/sister Grandparent

Sleep talking Mother Father Brother/sister Grandparent

Narcolepsy Mother Father Brother/sister Grandparent

Other: Mother Father Brother/sister Grandparent