REV. 09.27.2019

SLEEP CENTER LOCATION 3020 Hamaker Court Suite 401 Fairfax, VA 22031

For appointments: (703) 876-2850 For after-hour emergencies: (703) 876-5645

PLEASE FAX THIS SIGNED FORM TO (571) 308-1158 IN ORDER TO SCHEDULE YOUR SLEEP STUDY. THANK YOU.

SLEEP STUDY GUIDELINES

1. INSURANCE APPROVAL: Please sign and fax this form to (571) 308-1158. Once this form has been received, we will work to obtain approval from your insurance company. This process can take up to 4-6 weeks. Once we have received authorization from your insurance company, we will call you to schedule your sleep study. In some cases, your insurance company may only authorize a home sleep study. We will let you know.

2. SLEEP FORMS: Please complete all the forms in the sleep packet and bring them with you on the night of your sleep study.

3. ARRIVAL/ DEPARTURE: Please arrive at the sleep laboratory between 8:30 and 8:45 PM, and arrange to

leave by 5:30 AM the next morning. You will need to press the after-hours Neurology Center buzzer at the main doors to the building on Hamaker Court to obtain entry for your study.

4. ROOM: A private bedroom with bathroom (no shower) and television will be reserved for you. Please let us

know as early as possible if you must cancel or reschedule your sleep study.

5. WHAT TO BRING: If you wear a hearing aid, please bring that with you. Bring your own toiletries and loose, comfortable clothing to sleep in. If you will be staying for the daytime nap test (Multiple Sleep Latency Test), you may want to bring reading materials and/or your computer to help pass the time between the nap tests. Please also bring something to eat for breakfast and lunch.

6. BEFORE THE TEST: Please take a shower before coming to the sleep center. To help us obtain the most

accurate study, please do not put any type of gel, mousse, or spray into your hair. Also, please do not use any skin lotion, cream, or makeup.

7. MEALS: Please eat your normal dinner before coming to the sleep center. You will be finished with your

sleep study prior to breakfast time. Food and beverages are not kept in the sleep center.

8. NAPS: Try not to take any naps during the day before your test. We want you to be sleepy on the night of your sleep study.

9. ALCOHOL/CAFFEINE: Please refrain from all caffeinated and alcoholic beverages after 3:00 PM on the day of your sleep study.

10. MEDICATIONS: Please bring any medications you usually take at night and in the morning. 11. COLDS AND FLU: If you become sick before your sleep study, please reschedule the sleep study so that an

accurate test can be performed. Please call us as soon as possible to reschedule your test. 12. REGULATION: Smoking, alcohol use, illegal substances, or weapons of any type are strictly prohibited on

the premises.

13. CANCELLATION: Please provide at least 48-hours notice if you need to cancel your sleep study. A $250 fee will be charged if you cancel within 48-hours or do not show up for your sleep study.

14. FOLLOW-UP: Within 7-10 days of completing your sleep study, a staff member will call you by phone to

provide you with the results of your sleep study. You are welcome to obtain a copy of your sleep study report anytime.

If your sleep study shows sleep apnea, you will be referred to do a “treatment” sleep study with CPAP therapy. After completing this study, you will be notified of the results within 7-10 days and be given the option to receive new CPAP equipment at home to treat your sleep apnea. In all cases, please make sure to schedule a follow-up visit with your physician. You may also make an appointment to see our sleep specialist, Dr. Richard Cho. For more information about sleep apnea and CPAP therapy, please look in your packet or go to our website: http://yoursleepcenter.net

I UNDERSTAND THE ABOVE AND HAVE RECEIVED A COPY OF THIS FORM. PRINTED NAME DATE OF BIRTH PATIENT SIGNATURE DATE Primary Phone Number:

Secondary Phone Number:

Sleep Study Information Neurology Center of Fairfax

1) Your NCF physician may order a diagnostic sleep study (polysomnogram) to determine if you have a

sleep disorder.

2) Our billing department will work to obtain insurance approval for your diagnostic sleep study and

then will contact you to schedule the study.

3) The diagnostic sleep study will be performed at the Neurology Center of Fairfax (Suite 401).

4) If your diagnostic sleep study (polysomnogram) is normal, you will receive a letter in the mail. Please

follow up with your NCF physician for further care and management.

5) If your diagnostic sleep study shows sleep apnea, you will be contacted and a second sleep study for

CPAP (continuous positive airway pressure) titration will be ordered. This study will determine the best

pressure setting and mask fit to treat your sleep apnea.

Our billing department will work to obtain insurance approval for your CPAP titration study and then will

contact you to schedule the study.

6) After completing the CPAP titration study, Dr. Richard Cho (board-certified sleep specialist) will

provide an order so that you can receive the appropriate CPAP (Continuous Positive Airway Pressure)

equipment (machine, mask, tubing, etc.).

With your permission, the Neurology Center of Fairfax will submit your order and information to a

reputable durable medical equipment company (DME). This company will provide you with the CPAP

equipment. PLEASE VERIFY THAT YOU HAVE THE PROPER PREAUTHORIZATIONS FROM YOUR

INSURANCE COMPANY AND THAT THE DME COMPANY IS COVERED BY YOUR INSURANCE PLAN.

7) You may return to see your NCF physician before starting CPAP therapy to ask questions about your

diagnosis, sleep study results, and CPAP equipment. This is only if you desire to do so.

You also have the option to schedule a sleep-medicine consultation with Dr. Richard Cho, our board-

certified sleep specialist. This is suggested by your neurologist.

8) As a patient using CPAP therapy, you must follow up with your physician or Dr. Cho on a regular basis

in order to maintain insurance coverage of your CPAP equipment.

Medicare patients must have a face to face visit with their physician with documented sleep

issues/symptoms within 6 months of the order for CPAP equipment.

MEDICARE PATIENTS must be seen by a physician between 31 and 90 days after initiation of CPAP therapy. The home CPAP data report must show the use of CPAP > 4 hours per night on 70% of nights during a consecutive thirty-day period anytime during the first 3 months of initial usage. There also needs to be written documentation in the note that the patient is “using and benefitting from CPAP therapy” (exact wording). Questions about sleep studies should be directed to the Sleep Center at 703-876-0800 ext. 5043. Leave a message and your call will be returned.

Questions about sleep equipment (i.e. CPAP machines, mask) should be directed to the Nurse Sleep

Coordinator at 703-876-0800 ext. 1064. Leave a message and your call will be returned.

Rev. 08.29.2017

Patient Information

Appointment Date: Time of Appointment: Marital Status: S M D W Sex: M F

Last Name First Name Middle Name

Birthdate (Mo/Day/Yr)

Race: White American Indian or Alaska Native Black or African American

Asian Native Hawaiian or Other Pacific Islander Prefer not to say/Other

Ethnicity: Hispanic or Latino/a

Not Hispanic or Latino/a

Home Address

Street

City, State, Zip Code Email Address

Home Phone

( )

Cell Phone

( )

Business Phone

( )

Employer Name Employer Address

Employer Phone: ( )

With whom is your appointment? Date of Onset of Condition Appointment Reason

**Referring MD Name** **Referring MD Phone Number**

( )

**Primary Care Doctor Name** **Primary Care Doctor Phone Number**

( )

Primary Insurance Company Primary Ins. Phone

( )

Primary Ins. Policy Number Primary Ins. Group Number

Name of Insured Person - Primary Ins. Birthdate of Insured-Primary Relationship to Insured-Primary

Secondary Insurance Company Secondary Ins. Phone

( )

Secondary Ins. Policy

Number

Secondary Ins. Group Number

Name of Insured Person - Secondary Ins. Birthdate of Insured - Secondary Relationship to Insured-Secondary

Nearest Relative to Contact in Case of Emergency Address Phone

( )

** IS THIS AN ACCIDENT/ AUTO ACCIDENT/ LEGAL CASE? YES NO

** IS THIS A WORKERS COMPENSATION CASE? YES NO

** ARE YOU A MEDICARE PATIENT? YES* NO *If yes, please complete the reverse side of this form.

I certify the above information is correct. I understand I am responsible to notify the Neurology Center of Fairfax, LTD if my insurance coverage changes, if benefits change, or if the coverage I have reported is incorrect. I understand and agree that I am ultimately responsible for payment in full for services I receive from the Neurology Center of Fairfax, LTD.

Patient Signature Date

Rev. 07 17 2017

Patient Name: Date of Birth: :

MEDICARE PATIENTS ONLY

Are you in a rehabilitation facility? YES NO

Are you in a skilled nursing facility? YES NO

Are you in a nursing center? YES NO

Are you in hospice? YES NO

*If yes, please provide the name and address of the facility in the spaces below:

Facility Name:

Facility Address:

Rev. 07 17 2017

NAME__________________________________ DOB ________________ PATIENT #________________

Past Medical HistoryYES YES

Hypertension (High Blood Pressure) Muscle DiseaseCoronary Disease/Heart Attack/Angina FibromyalgiaHeart Disease – Any Heart Problem Myasthenia GravisAtrial Fibrillation or Irregular Heartbeat Nerve Pain - NeuralgiaHigh Cholesterol Nerve PalsyDiabetes Mellitus Neuropathy

Type 1(Childhood/Juvenile) Radiculopathy (Pinched/Trapped Nerve)Type 2 (Adult onset) Cervical

Arthritis/Osteoarthritis ThoracicCancer (including Skin) LumbarThyroid Disorders (Hyper- or Hypothyroid) ParalysisOther Endocrine (PCOS / Cushings) Stroke / TIAGI Disorders / Reflux / GERD Carotid Disease / StenosisStomach Ulcer / GI Bleed Intracranial HemorrhageLiver Disease Brain AneurysmEye Disease/Vision Loss/Double Vision DementiaLung Disease (Asthma/COPD) Parkinson's DiseasePneumonia TremorKidney Disease – Any Kidney Problem Multiple SclerosisHistory of Infections – incl. Lyme, HIV, Hepatitis Autoimmune Disease – SLE, Rheum., SjogrenBlood Disease / Disorder Depression / Other Psychiatric DisordersSeizure Disorder / Epilepsy Genetic Disease (yours)Fainting (Syncope) Brain TumorSleep Disorders / Narcolepsy / Restless Legs Surgeries – List BelowSleep Apnea Cervical Spine (Neck) Surgery – date(s)Migraine Headache Thoracic Spine Surgery – date(s)Other Headache Condition – Type: Lumbar Spine Surgery – date(s)

Other Surgeries – List BelowOther Medical History List Below None/Negative

Additional Information/ Other medical history/tests not listed:

Rev. 2.2020

Fairfax Office 3020 Hamaker Ct, Suite 400, Fairfax, VA 22031

Reston Office 1830 Town Center Dr. Suite 305, Reston, VA 20190

Office Phone 703.876.0800 | Fax 703.876.0866 | After hours emergency 703.755.1450

NAME__________________________________ DOB ________________ PATIENT #________________

Past Medical HistoryYES YES

Hypertension (High Blood Pressure) Muscle DiseaseCoronary Disease/Heart Attack/Angina FibromyalgiaHeart Disease – Any Heart Problem Myasthenia GravisAtrial Fibrillation or Irregular Heartbeat Nerve Pain - NeuralgiaHigh Cholesterol Nerve PalsyDiabetes Mellitus Neuropathy

Type 1(Childhood/Juvenile) Radiculopathy (Pinched/Trapped Nerve)Type 2 (Adult onset) Cervical

Arthritis/Osteoarthritis ThoracicCancer (including Skin) LumbarThyroid Disorders (Hyper- or Hypothyroid) ParalysisOther Endocrine (PCOS / Cushings) Stroke / TIAGI Disorders / Reflux / GERD Carotid Disease / StenosisStomach Ulcer / GI Bleed Intracranial HemorrhageLiver Disease Brain AneurysmEye Disease/Vision Loss/Double Vision DementiaLung Disease (Asthma/COPD) Parkinson's DiseasePneumonia TremorKidney Disease – Any Kidney Problem Multiple SclerosisHistory of Infections – incl. Lyme, HIV, Hepatitis Autoimmune Disease – SLE, Rheum., SjogrenBlood Disease / Disorder Depression / Other Psychiatric DisordersSeizure Disorder / Epilepsy Genetic Disease (yours)Fainting (Syncope) Brain TumorSleep Disorders / Narcolepsy / Restless Legs Surgeries – List BelowSleep Apnea Cervical Spine (Neck) Surgery – date(s)Migraine Headache Thoracic Spine Surgery – date(s)Other Headache Condition – Type: Lumbar Spine Surgery – date(s)

Other Surgeries – List BelowOther Medical History List Below None/Negative

Additional Information/ Other medical history/tests not listed:

Rev. 2.2020Rev. 2.26.2020

No Significant Family History Family history is unobtainable

Patient adopted Patient orphaned

Mother Father Sister Brother

Diabetes MellitusHypertension/High Blood PressureHeart Disease – Any heart problemCoronary Disease/Heart Attack/AnginaAtrial Fibrillation – Irregular HeartbeatHeart failure (CHF)High CholesterolArthritisCancer (including Skin)Thyroid Disorders – Hyper/HypoOther Endocrine DisorderGI Disorders / Stomach DisorderLiver DiseaseEye Disease / Vision LossLung Disease

Kidney Disease – any typeBlood Disease / DisorderSeizure Disorder/EpilepsyFainting/ Passing Out

Mother Father Sister Brother

Sleep Disorder / Narcolepsy / Restless LegsSleep ApneaMigraine/Other Headache ConditionPeripheral Nerve/MusclePolyneuropathy - NeuropathyStroke / TIA / ParalysisIntracranial HemorrhageDementiaParkinson’s DiseaseTremorPsychiatric Disorders

DepressionAnxiety

Genetic DiseaseAutoimmune Disease - SLE / Rheumatoid

Multiple SclerosisBrainTumorOther illness not listed

NAME__________________________________ DOB ________________ PATIENT #________________

Family and Social History

Occupation:Y N Working Full Time

Occupation:______________________Y N Working Part Time

Occupation: _____________________Y N UnemployedY N HomemakerY N RetiredY N Currently on disabilityY N StudentY N Military service

Exercise HabitsY Good exercise habits (≥ 3 days/wk)Y Poor exercise habits

Marital HistoryY N Currently marriedY N Domestic PartnerY N SingleY N SeparatedY N DivorcedY N Widowed

Alcohol AssessmentY N Do you drink alcohol?Y N Social drinker

Y N 2 or less drinks/day

Y N More than 2 drinks/day

Y Right-handedY Left-handed

Y N Caffeine Use

Tobacco Assessment:

Y N Do you use tobacco products?Y N Current every day smokerY N Current some day smokerY N Former smokerY N Never smokedY N Smoker, status unknownY N Unknown if ever smoked

Are You:

Fairfax Office 3020 Hamaker Ct, Suite 400, Fairfax, VA 22031

Reston Office 1830 Town Center Dr. Suite 305, Reston, VA 20190

Office Phone 703.876.0800 | Fax 703.876.0866 | After hours emergency 703.755.1450

NAME: ____________________________________DOB: ________________ PATIENT # __________________

REVIEW OF SYSTEMS(Please check box next to symptoms you have had in the past 3 months)

Constitutional Symptoms

Head Symptoms

Neck Symptoms

Eye Symptoms

Skin Symptoms

Hematologic Symptoms

Respiratory Symptoms

Weight ChangeChange in appetiteChills / Fever Other: ________________

Easy bleedingAnemiaBlood ClotsOther: ________________

Itching RashesEasy bruisingOther: ________________

Blurry visionSeeing double (diplopia)Total loss of visionSeeing flashing lights Other: ________________

Pain in neckStiffnessNeck pain radiating down armOther: ________________

HeadacheFacial Pain Other: ________________

Shortness of breathCoughOther: ________________

Genitourinary SymptomsIncreased urinary frequencyUrinary loss of controlUrinary tract infectionPain during urinationSexual dysfunctionOther: ________________

Ear, Nose & Throat (ENT)

Back Symptoms

Hearing LossRinging in the ears (tinnitus)Vertigo/dizziness/lightheadedSinus PainTaste or smell disturbanceOther: __________________

Back Pain Lower back pain radiating to the legsLeg pain with exercise (claudication)Other: ________________

Neurological SymptomsHeadache/facial painMemory lapses or lossConfused or disorientedTotal loss of visionWorsening visionSeeing double (diplopia)Hearing LossRinging in the ears (tinnitus)Dizziness / Vertigo / Light HeadednessDifficulties in speech Difficulty swallowing (dysphagia)Bowel/bladder changesSexual complaintsLocalized pain/where:________Generalized painNumbness (hypesthesia)/tinglingFeeling tired (fatigue)Muscle weaknessMuscle crampsWalk is wobbly or unsteady(ataxia)Poor coordinationTremorConvulsions/seizuresFainting/passing outTransient alteration of awarenessSleep disturbancesHead injury / ConcussionSpinal cord disease

Musculoskeletal SymptomsDiffuse joint painsPain in arms/handsPain in the legs/feetMuscle aches/muscle painMuscle twitches (Fasciculations)Muscle crampsOther: ________________

Gastrointestinal SymptomsDifficulty swallowingNausea/ VomitingAbdominal painLiver DiseaseDiarrheaConstipationOther: ________________

Cardiovascular SymptomsChest pain or discomfortPalpitations/ rapid heart beatIrregular HeartbeatLeg SwellingOther: ________________

Gynecological SymptomsHistory of __ pregnancy(s)Other gynecological historyOther: ________________

Endocrine SymptomsExcess ThirstHeat or Cold IntoleranceOther: ________________

I HAVE REVIEWED ALL BOXES (UNCHECKED BOXES = “NO”)

Sleep SymptomsSnoringGasping at nightInsomniaDaytime sleepinessRestless legsOther: ________________

Psychiatric SymptomsAnxietyDepressionUnable to control angerHallucinationsOther: ________________

Allergic/ ImmunologicDrug/ Food/ Pet AllergiesHivesOther: ________________

Rev 02.26.2020

Original To Patient - Copy To Doctor

Medication List

Please include all prescriptions, vitamins, and over-the-counter medications.

Name: ___________________________ Pharmacy:_______________________

Pharmacy

DOB: __________________________ Phone:__________________________

Pharmacy

Cell Phone:_______________________ Fax: ____________________________ Medication/Allergies:_____________________________________________________________________________ ________________________________________________________________________________________________

Medication Dosage Frequency/Time Prescribed By Taken For

COPY PAGE AS NECESSARY

Rev. 07/17/2017

Rev. 12.19.2017

SLEEP HEALTH QUESTIONNAIRE

Patient Name: Date:

Present height: ___________ Present weight: ___________ DOB: ________________

1. Please state in your own words the reason for a sleep evaluation.

2. Have you had a previous sleep evaluation? If so, when and what were the results?

3. Please check any of the following that may affect your sleep:

Snoring Morning dry mouth Chest pain Choking sensation Morning headache Sweating at night Shortness of breath Heart racing ---------------------------------------------------------------------------------------------------------------- ------------------------------------------------------ Difficulty falling asleep Worried about not sleeping Waking up before alarm Many awakenings Anxiety/ racing thoughts Sleeping better when away from home Restless sleep Sadness or depression ----------------------------------------------------------------------------------------------------------------------------- ----------------------------------------- Urge to move legs Leg/foot cramps Muscle tension Relief with movement Pain or discomfort Worse at night Creepy-crawly feeling ----------------------------------------------------------------------------------------------------------------------------- ----------------------------------------- Nightmares/ bad dreams Wake up confused Eating at night Wake up in a panic Acting out dreams Wet the bed Wake up screaming Sleep walking Seizure movements Wake up with violence Sleep talking ----------------------------------------------------------------------------------------------------------------------------------------------------- ----------------- Feeling unable to move Daytime sleep attacks Sounds/images when falling asleep or waking up Does your body get weak when you become emotional (i.e. laughter)? ----------------------------------------------------------------------------------------------------------------------------- ----------------------------------------- Noise Room temperature Bed partner/moving Caring for children Other (please describe): ----------------------------------------------------------------------------------------------------------------------------- -----------------------------------------

4. Have you had a motor vehicle crash (or near-miss) due to daytime sleepiness? If so, how often and/or when did it occur?

______________________________________________________________________________________________________

5. How much weight have you gained or lost in the past 1 year?

How often do you exercise? __________________________ What time of the day?

Rev. 12.19.2017

6. Are these activities you do in the bedroom at night?Please circle the most appropriate answer.

Watch TV NEVER LESS THAN ONE NIGHT 2-3 NIGHTS 2-3 NIGHTS MOST EVERY

ONCE PER PER MONTH PER MONTH PER WEEK NIGHTS NIGHT MONTH

Use a computer NEVER LESS THAN ONE NIGHT 2-3 NIGHTS 2-3 NIGHTS MOST EVERY

ONCE PER PER MONTH PER MONTH PER WEEK NIGHTS NIGHT MONTH

Work NEVER LESS THAN ONE NIGHT 2-3 NIGHTS 2-3 NIGHTS MOST EVERY

ONCE PER PER MONTH PER MONTH PER WEEK NIGHTS NIGHT MONTH

Read or study NEVER LESS THAN ONE NIGHT 2-3 NIGHTS 2-3 NIGHTS MOST EVERY

ONCE PER PER MONTH PER MONTH PER WEEK NIGHTS NIGHT MONTH

Talk on phone NEVER LESS THAN ONE NIGHT 2-3 NIGHTS 2-3 NIGHTS MOST EVERY

ONCE PER PER MONTH PER MONTH PER WEEK NIGHTS NIGHT MONTH

Listen to radio NEVER LESS THAN ONE NIGHT 2-3 NIGHTS 2-3 NIGHTS MOST EVERY

ONCE PER PER MONTH PER MONTH PER WEEK NIGHTS NIGHT MONTH

Eat NEVER LESS THAN ONE NIGHT 2-3 NIGHTS 2-3 NIGHTS MOST EVERY

ONCE PER PER MONTH PER MONTH PER WEEK NIGHTS NIGHT MONTH

7. SLEEP SCHEDULE

What time do you go to bed?

Do you take any sleep aids? How often?

How long does it take you to fall asleep?

How many times do you wake up during the night?

What time do you wake up in the morning? Do you feel refreshed in the morning?

How often do you take naps?

8. What are your work hours? __________________________ What days do you work? ______________________________

Rev. 12.19.2017

9. HABITS

Do you drink caffeinated coffee? yes no If yes, how many cups per day? Do you drink caffeinated tea? yes no If yes, how many cups per day? Do you drink caffeinated soda? yes no If yes, how many cans per day?

What time is your last drink? _______

Do you drink wine? yes no If yes, how much per day or week? Do you drink beer? yes no If yes, how much per day or week? Do you drink mixed drinks? yes no If yes, how much per day or week?

What time is your last drink? _______

Do you smoke cigarettes? yes no If yes, how many per day? Do you smoke cigars? yes no If yes, how many per day? Do you chew tobacco? yes no If yes, how much per day?

What time was your last use? How long have you used tobacco? _________________________

Do you have a history of non-prescription drug use? If so, please list what you have used:

10. How likely are you to doze off or fall asleep in the following situations? Even if you have not done some of these thingsrecently, try to think about what would happen in these situations. Use the following scale to choose the most appropriate number for each situation.

0 = would never doze off 1 = slight chance of dozing off 2 = moderate chance of dozing off 3 = high chance of dozing off

SITUATION CHANCE OF DOZING

Sitting and reading 0 1 2 3

Watching TV 0 1 2 3

Sitting quietly in a public place (i.e. theatre or meeting) 0 1 2 3

As a passenger in a car for an hour without a break 0 1 2 3

Lying down to rest in the afternoon when able to 0 1 2 3

Sitting and talking to someone 0 1 2 3

Sitting quietly after a lunch without alcohol 0 1 2 3

In a car, while stopped for a few minutes 0 1 2 3

Rev. 12.19.2017

Feelings Survey: Please read each statement carefully and pick out the one that best describes how you have been feeling over the past 2 weeks, including today. Circle only one number (0 through 3) for the statement you have picked. 1 12

0 I do not feel sad. 0 I have not lost interest in other people or activities. 1 I feel sad much of the time. 1 I am less interested in other people or things than before. 2 I am sad all of the time. 2 I have lost most of my interest in other people or things. 3 I am so sad or unhappy that I cannot stand it. 3 It’s hard to get interested in anything.

2 13 0 I am not discouraged about my future. 0 I make decisions about as well as ever. 1 I feel more discouraged about my future than I used to be. 1 I find it more difficult to make decisions than usual. 2 I do not expect things to work out for me. 2 I have much greater difficulty in making decisions than I used to. 3 I feel my future is hopeless and will only get worse. 3 I have trouble making any decisions.

3 14 0 I do not feel like a failure. 0 I do not feel I am worthless. 1 I have failed more than I should have. 1 I don’t consider myself as worthwhile and useful as I used to. 2 As I look back, I see a lot of failures. 2 I feel more worthless as compared to other people. 3 I feel I am a total failure as a person. 3 I feel utterly useless.

4 15 0 I get as much pleasure as I ever did from the things I enjoy. 0 I have as much energy as ever. 1 I don’t enjoy things as much as I used to. 1 I have less energy than I used to have. 2 I get very little pleasure from the things I used to enjoy. 2 I don’t have enough energy to do very much. 3 I can’t get any pleasure from the things I used to enjoy. 3 I don’t have enough energy to do anything

5 16 0 I don’t feel particularly guilty. 0 I have not experienced any change in my sleeping pattern. 1 I feel guilty over many things I have done or should have done. 1a I sleep somewhat more than usual. 2 I feel quite guilty most of the time. 1b I sleep somewhat less than usual. 3 I feel guilty all of the time. 2a I sleep a lot more than usual.

2b I sleep a lot less than usual. 6 3a I sleep most of the day.

0 I don’t feel I am being punished. 3b I wake up 1-2 hours early and can’t get back to sleep. 1 I feel I may be punished. 2 I expect to be punished. 17 3 I feel I am being punished. 0 I am no more irritable than usual.

1 I am more irritable than usual. 7 2 I am much more irritable than usual.

0 I feel the same about myself as ever. 3 I am irritable all the time. 1 I have lost confidence in myself. 2 I am disappointed in myself. 18 3 I dislike myself. 0 I have not experienced any change in my appetite.

1a My appetite is somewhat less than usual. 8 1b My appetite is somewhat greater than usual.

0 I don’t criticize or blame myself more than usual. 2a My appetite is much less than usual. 1 I am more critical of myself than I used to be. 2b My appetite is much greater than usual. 2 I criticize myself for all of my faults. 3a I have no appetite at all. 3 I blame myself for everything bad that happens. 3b I crave food all the time.

9 19 0 I don’t have any thoughts of killing myself. 0 I can concentrate as well as ever. 1 I have thoughts of killing myself, but I would not carry them out. 1 I can’t concentrate as well as usual. 2 I would like to kill myself. 2 It’s very hard to keep my mind on anything for very long. 3 I would kill myself if I had the chance. 3 I find I can’t concentrate on anything.

10 20 0 I don’t cry anymore than I used to. 0 I am no more tired or fatigued than usual. 1 I cry more than I used to. 1 I get more tired or fatigued more easily than usual. 2 I cry over every little thing. 2 I am too tired or fatigued to do a lot of things I used to do. 3 I feel like crying, but I can’t. 3 I am too tired or fatigued to do most of the things I used to do.

11 21 0 I am no more restless or wound up than usual. 0 I have not noticed any recent change in my interest in sex. 1 I feel more restless or wound up than usual. 1 I am less interested in sex than I used to be. 2 I am so restless or agitated that it’s hard to stay still. 2 I am much less interested in sex now. 3 I am so restless or agitated that I have to keep moving or 3 I have lost interest in sex completely.

doing something.

Rev. 07/17/2017

DETAILS

CONSENT FOR POLYSOMNOGRAM

A polysomnogram is an overnight sleep study. It records detailed information that shows how your body acts while you sleep. A technologist will attach sensors to your body for the study. These sensors will monitor and record multiple body functions which include:

• Brain wave activity

• Heart rate and rhythm

• Breathing patterns

• Oxygen level

• Eye movements

• Chin movement

The study also may involve other sensors. These sensors send signals to a computer. The sleep center will use this information to prepare a detailed report about your sleep. The doctor who sent you to the sleep center will receive a copy of this report. He or she will then discuss the results with you. Please allow 14 business days for your doctor to receive your sleep report.

RISKS You will sleep in the Sleep Laboratory as you would at home or in a hotel room.

AGREEMENT My signature below indicates that I understand and agree with the following statements:

1. This sleep study may not detect the cause of my sleep problem.2. A technologist will attach sensors to my body for the study.3. These sensors may smell bad when they are placed on me.4. The removal of the sensors in the morning may irritate my skin and cause redness.5. A video camera will record me as I sleep. A technologist will watch me on a monitor in

the control room.6. I will be free to roll over and move in bed during the study.7. I will need to ask for help if I must get out of bed for any reason.8. The technologist may need to enter the room and wake me if there is a problem.9. The study may show that I stop breathing many times during the night. If this happens, a

technologist may enter my room to start treatment. This treatment is called positiveairway pressure, or PAP. To use this treatment, I will need to wear a mask which coversmy nose and possibly my mouth.

10. I understand why I am taking this sleep study.11. I have discussed the need for the sleep study with my referring doctor.12. The sleep center staff has explained the sleep study to me. I understand what is going to

happen during the study.

All of my questions have been asked and satisfactorily answered. I agree to the performance of a sleep study with video recording.

Signature (Patient or Guardian) Date

Signature (Witness) Date

REV 07.17.17

PERMISSION TO PHOTOGRAPH AND/OR RECORD AUDIO AND VIDEO

I, _, Patient/Guardian

hereby authorize The Neurology Center of Fairfax/ Sleep Diagnostic and Treatment Center, or their representative, to take photograph(s) and/or record audio and video

of _. Name of Patient

I understand that such photograph(s), audio recording(s) and/or video recordings may be used for clinical or educational purposes, or in the event of legal action. The sleep center and directors of The Neurology Center of Fairfax, Ltd. and its duly appointed representatives are hereby released without recourse from any liability arising from obtaining and using such photograph(s), audio recording(s) and/or video recordings.

The undersigned also hereby transfers and assigns to The Neurology Center of Fairfax/ Sleep Diagnostic and Treatment Center the right to copy the materials in whole or in part. No use of the material for educational purposes will identify me by name.

Check here if you do NOT authorize use for educational purposes.

Signature (patient or guardian) Date

Relationship to Patient if Guardian

Witness Date

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU

CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

For questions about this notice, please contact the Privacy Officer at (703) 876-0800, or at Neurology Center of Fairfax, Ltd., 3020 Hamaker Ct., Ste. 400, Fairfax, VA 22031.

WHO WILL FOLLOW THIS NOTICE. This notice describes the practices of Neurology Center of Fairfax, Ltd. (“NCF”), its physicians, employees, staff and other personnel.

OUR PLEDGE REGARDING MEDICAL INFORMATION: We understand that medical information about you and your health (PHI), including genetic information, is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at NCF. We need this record to provide you with quality care and to comply with certain legal requirements.

This notice applies to all of the records of your care generated for services at NCF.

This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information. We are required by law to:

• make sure that medical information that identifies you is kept private;

• give you this notice of our legal duties and privacy practices with respect to medical information about you;

• to notify affected individuals of any breach of unsecured protected health information; and

• follow the terms of the notice as in effect from time to time.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU. The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures we will explain what we mean and/or try to give

some examples. Not every use or disclosure in a category will be listed.

➢➢ For Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to physicians, nurses, technicians, or other NCF personnel and others outside of NCF who are involved in taking care of you. For example, a physician treating you for another condition may need to know what medications we have prescribed for you. Different individuals at NCF also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and similar care. We may make a professional judgment to determine whether it is in your best interest to disclose medical information about you to people outside NCF who may be involved in your medical care, such as other physicians, or family members involved in your treatment or others.

➢➢ For Payment. We may use and disclose medical information about you so that the treatment and services you receive at NCF may be billed to and payment may be collected from

you, an insurance company or a third party. For example, we may need to give your health plan information about care you received at NCF so your health plan will pay us or

reimburse you for the care. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the

treatment.

➢➢ For Health Care Operations. We may use and disclose medical information about you for NCF health care operations. These uses and disclosures are necessary to run NCF and

make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our

staff in caring for you. We may also combine medical information about many NCF patients to decide what additional services NCF should offer, what services are not needed, and

whether certain new treatments are effective. We may also disclose information to doctors, nurses, and technicians and other personnel for review and learning purposes. We may

also combine the medical information we have with medical information from other health care facilities to compare how we are doing and see where we can make improvements

in the care and services we offer.

➢➢ Business Associates. We are permitted by law to utilize Business Associates to carry out treatment, payment or health care operations, functions that may involve creating, receiving,

or transmitting information and disclosure of some of your health information. For example, we may use a billing service or accounting service or some other non-NCF employee

arrangement to handle some billing and payment functions. We may also use health care consultants to assist us in improving or upgrading services we offer to patients. However,

in any such instance, unless the disclosure of health information is to another health care provider for the purpose of providing treatment to you, we will have entered into a formal

Agreement with the Business Associate that requires the Business Associate to maintain the confidentiality of any patient information received and generally requires the Business

Associate to limit its use of such information to only the purpose for which it was disclosed by us. ➢➢ Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at NCF.

➢➢ Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you. ➢➢ Health-Related Benefits and Services. We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.

➢➢ Individuals Involved in Your Care or Payment for Your Care. Unless you object, we may release medical information about you to a friend or family member who is involved

in your medical care. We may also give information to someone who helps pay for your care. We may also use and disclose information about you to notify, or to assist in notifying, a family member or friend of your location or condition, but except in emergency circumstances, you will generally be given an opportunity to object.

➢➢ Research. Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the

health and recovery of all patients who received one medication to those who received another, for the same condition. Where consistent with the research goals and purposes, we

will use or disclose only de-identified information, so that your identity cannot be ascertained from the information disclosed.

When research cannot be conducted with such de-identified information, we will usually ask for your specific authorization for such use or disclosure. However, some research

projects that involve information gathering may be adversely affected by requiring prior patient authorization before otherwise confidential information can be used or disclosed for

research purposes. In those circumstances, research projects are subject to a specific and comprehensive approval process. This process evaluates the proposed research project and

its use of medical information, trying to balance research needs with patients’ rights to privacy of medical information. Before we use or disclose medical information for research

under such circumstances, the project will have been approved by an Institutional Review Board (IRB) or a specially designated privacy board, which will be required to determine

whether the nature of the research is such that it could not be conducted if prior patient authorization was required and will be required to determine that adequate protections are in

place to protect patient information from unauthorized use or disclosure. However, as part of the research process we may disclose medical information about you to individuals preparing to conduct the research project, for example, to help them look for patients with specific medical needs, but any such medical information will not be allowed to leave our

offices. ➢➢ As Required By Law. We will disclose medical information about you when required to do so by federal, state or local law.

➢➢ To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or

the health and safety of the public or another person, consistent with applicable law. Any disclosure, however, would only be to someone able to help prevent or lessen the threat.

SPECIAL SITUATIONS ➢➢ Organ and Tissue Donation. If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue

transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

➢➢ Military and Veterans. If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also

release medical information about foreign military personnel to the appropriate foreign military authority.

➢➢ Workers' Compensation. Where required or permitted by state law, we may release medical information about you for workers' compensation or similar programs. These

programs provide benefits for work-related injuries or illness. ➢➢ Public Health Risks. Where required or permitted by state and federal law, we may disclose medical information about you for public health activities. These activities generally

include the following:

• to prevent or control disease, injury or disability;

• to report births and deaths;

• to report child abuse or neglect;

• to report reactions to medications or problems with products;

• to notify people of recalls of products they may be using;

• to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Effective Date: October 27, 2020

➢➢ Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example,

investigations, audits, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with

civil rights laws.

➢➢ Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also

disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been

made to tell you about the request or to obtain an order protecting the information requested.

➢➢ Law Enforcement. We may release medical information if asked to do so by a law enforcement official:

• In response to a court order, subpoena, warrant, summons or similar process;

• To identify or locate a suspect, fugitive, material witness, or missing person;

• About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement;

• About a death we believe may be the result of criminal conduct;

• About criminal conduct at our offices; and

• In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

➢➢ Coroners, Medical Examiners and Funeral Directors. We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients of NCF to funeral directors as necessary to carry out their duties.

➢➢ National Security and Intelligence Activities. We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national

security activities authorized by law.

➢➢ Protective Services for the President and Others. We may disclose medical information about you to authorized federal officials so they may provide protection to the President,

other authorized persons or foreign heads of state or for the conduct of special investigations.

➢➢ Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional

institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and

safety of others; or (3) for the safety and security of the correctional institution.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU. You have the following rights regarding medical information we maintain about you:

➢➢ Right to Inspect and Copy. You have the right to inspect and obtain copies, or get electronic copies, of your medical information that may be used to make decisions about your

care. Usually, this includes medical and billing records, but does not include psychotherapy notes, which are notes separate from the medical record made during individual or group counseling.

To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the Privacy Officer at the address set forth

above. If you request a copy of the information, there will be a charge for labor, supplies, and postage. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed

by another licensed health care professional. We will comply with the outcome of the review.

➢➢ Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an

amendment for as long as the information is kept by or for NCF.

To request an amendment, your request must be made in writing and submitted to the Privacy Officer at the address set forth above. In addition, you must provide a reason that

supports your request.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to

amend information that:

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;

• Is not part of the medical information kept by or for NCF;

• Is not part of the information which you would be permitted to inspect and copy; or

• Is accurate and complete.

You will be informed of the decision regarding any request for amendment of your medical information and, if we deny your request for amendment, we will provide you with

information regarding your right to respond to that decision. ➢➢ Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of medical information about you. In

most cases, this list will not include disclosures made for purposes of treatment, payment, or health care operations, or that were made in response to a specific authorization from

you.

To request this list or accounting of disclosures, you must submit your request in writing to the Privacy Officer at the address set forth above. Your request must state a time

period for the request (i.e. the period covered by the accounting) which may not be longer than six years prior to the date of the request. The first list you request within a 12

month period will be free. For additional accountings, there will be a charge.

➢➢ Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a

family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. We are not required to agree to your request, other than a

request that we not disclose information to a health plan for payment or health care operations where the request is not required by law and relates only to a health care item or

service for which you or a person other than the health plan has paid in full. If we do agree, we will comply with your request unless the information is needed to provide you

emergency treatment.

To request restrictions, you must make your request in writing to the Privacy Officer at the address set forth above. In your request, you must tell us (1) what information you

want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.

➢➢ Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. We do not communicate by regular e-mail, but our Patient Portal does support a form of secure e-mail.

To request confidential communications, you must make your request in writing to the Privacy Officer at the address set forth above. We will not ask you the reason for your

request. Your request must specify how or where you wish to be contacted. We reserve the right to determine our capability to accommodate your request.

➢➢ Other Rights and Terms

• You may opt out of communications regarding subsidized treatments.

• We may not use or disclose your PHI for any marketing communications unless you provide written authorization.

• We may not disclose psychotherapy notes about you unless you provide written authorization for NCF to disclose those notes.

• We may not sell your PHI unless you provide written authorization for NCF to do so.

➢➢ Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

To obtain a paper copy of this notice, contact the Privacy Officer.

CHANGES TO THIS NOTICE ➢➢ We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any

information we receive in the future. We will post a copy of the current notice at our offices. The notice will contain on the first page, in the top right-hand corner, the effective date.

You may also obtain a copy of any current notice by submitting a written request to the Privacy Officer at the address set forth above.

COMPLAINTS If you believe your privacy rights have been violated, you may file a complaint with NCF or with the Secretary of the Department of Health and Human Services. To file a complaint

with NCF, contact the Privacy Officer at the phone number or address set forth above. All complaints to the Department of Health and Human Services must be submitted in writing.

You will not be penalized or subject to retaliation for filing a complaint.

OTHER USES OF MEDICAL INFORMATION. Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written authorization. If you provide us with

authorization to use or disclose medical information about you, you may revoke that authority, in writing, at any time. If you revoke your authorization, we will no longer use or disclose

medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made in reliance

upon your prior authorization, and that we are required to retain our records of the care that we provided to you.

Rev. 10-27-2020

Patient Authorizations

Patient Name: __________________________________________________________________ Date of Birth: ____________________________

(Please read carefully. You are authorizing these actions.)

I hereby authorize the Neurology Center of Fairfax, Ltd. (NCF) to apply for benefits on my behalf for covered services rendered by NCF, to myself or to my dependent. Authorization is effective as of today. I request payment from my insurance carrier and/or Medicare Part B to be made directly to NCF.

I certify that the information I have reported with regard to my insurance coverage is correct and further authorize the release of any necessary information, including protected health information (PHI) for this or any other related claim, to my insurance carrier or in the case of Medicare Part B benefits to the Social Security Administration and Centers for Medicare and Medicaid Services (CMS). I permit a copy of this authorization to be used in place of an original. It is possible that services provided to me by NCF may not be covered by Medicare or by my insurance. I agree to assume responsibility for full payment of all services if Medicare or other insurance payment is denied. I further agree to be responsible for the outstanding balance on this account and to pay all reasonable costs of collection including attorney’s fees at 40% of the outstanding balance and monthly interest at 1.5%, should this account become overdue.

I understand that payment for all services is due and payable in full at the time of service, and that full payment for services may be required at the time of service. This includes, but is not limited to, my co-payment, co-insurance and deductibles. I agree to provide NCF with my current insurance card, government issued identification, and a valid referral (if required) at the time services are rendered. I understand that it is my responsibility to obtain required referrals. I understand that although my insurance may pay part or all of the charges I incur, I am still ultimately liable and responsible for all charges. I understand that it is my responsibility to know the correct amount of my co-payment and deductible. I understand that my co-payments, co-insurance, and any deductibles are due at the time of service. I understand there is a $10 administrative fee if I do not pay my co-payment, co-insurance, and deductible at the time of service, and a separate $10 administrative fee each time a bill is generated for payment due, but not paid at the time of service. I understand I will be charged a “no-show” fee for any missed appointment or any appointment not cancelled more than 24 hours in advance.

I authorize NCF to release my medical records (protected health information) to my treating physicians and other healthcare providers and to discuss my care with those providers, as my physician deems necessary. I authorize NCF to contact the people whom I list as emergency contacts in the event of an emergency. I authorize NCF to obtain contact information from my other health care providers, my emergency contacts, my employer or my health insurance carrier, if NCF is unable to contact me directly for any reason. I authorize my treating NCF physician to provide information to my caregiver or a family member, if my physician judges this disclosure to be important for my well-being. I authorize NCF to leave messages for me on answering devices attached to my telephones or to contact me by email or text message. I authorize NCF to contact me by email to inform me that information is available for me on the NCF secure patient portal. These authorizations may be revoked by me at any time in writing. I agree that a facsimile or a scanned copy of this agreement may be treated as an original for all purposes. I take these actions in Fairfax County, Virginia.

I acknowledge I have received a copy of the Neurology Center of Fairfax, Ltd.’s Notice of Privacy Practices dated October 27, 2020. I have read, I understand, and I agree to the terms and conditions specified in this Notice of Privacy Practices

Signature:_____________________________ Date: ________________________ ****************************************************************************************************************************************************************************

For Patients Who Do Not Have Their Insurance Card, and/or Referral, If Required, (includes Work Comp)

I acknowledge that I did not bring a referral as required by my insurance company and/or do not have my

insurance card. I am electing to be seen today and agree to pay in full today for the services rendered today

since I do not have a valid referral and/or insurance card, or worker’s comp authorization.

Signature: ____________________________________________ Date: _________________________ Rev. 10.27.2020

**If the patient is under the age of 18, please complete the following: The undersigned is a parent/guardian of the patient and executes this form on behalf of the patient.

Name: _______________________________________________ Relationship: _______________________

Signature: ____________________________________________ Date: ______________________________