Healthcare OSA Form

Healthcare OSA Form

Patient Information

Date of Birth:    Gender: Male Female Other / Prefer not to state

Emergency Contact

Insurance & Provider Information

Medical History & Symptoms

Chronic Conditions (check all that apply): Hypertension Diabetes Cardiovascular disease COPD / Asthma Hypothyroidism Other

OSA-Specific Screening

Please indicate if you experience any of the following (check all that apply):

Loud snoring Witnessed apneas Excessive daytime sleepiness Morning headaches Nocturia (waking to urinate) Gasping / choking at night

Epworth Sleepiness Scale

For each situation below, indicate your chance of dozing: 0 = no chance, 1 = slight, 2 = moderate, 3 = high.

Assessment & Consent for Evaluation / Treatment

The undersigned consents to diagnostic evaluation and treatment for suspected obstructive sleep apnea (OSA), which may include in-laboratory polysomnography, unattended home sleep testing, titration studies, and initiation or adjustment of positive airway pressure therapy or an oral appliance. I understand that testing and treatment are intended to identify and reduce sleep-disordered breathing and its health consequences.

Risks associated with diagnostic testing and common treatments include, but are not limited to: discomfort during testing, skin irritation from monitoring devices, nasal congestion, dry mouth, aerophagia, claustrophobia, dental or bite changes with oral appliances, mask leaks, pressure intolerance, and rare adverse cardiopulmonary events. Alternatives to the recommended evaluation and treatment, including conservative measures and observation, have been described by my provider.

I have had the opportunity to ask questions and I understand that I may withdraw consent at any time prior to a procedure or initiation of therapy without affecting my right to future care. Withdrawal of consent for ongoing therapy will be handled according to clinical policies and may require follow-up evaluation.

By checking the boxes below I provide specific consent where indicated:

Consent to in-laboratory polysomnography (overnight sleep study)
Consent to unattended home sleep test (portable monitoring) where clinically appropriate
Consent to positive airway pressure therapy (CPAP/APAP) if clinically indicated
Consent to oral appliance therapy evaluation and fitting if recommended

Authorization for Use and Release of Health Information

I authorize the release of my relevant medical records, including sleep study results, diagnostic reports, and billing information, to my insurance company and to other healthcare providers involved in my care for the purposes of treatment, payment, and continuity of care. I understand that this information may include diagnosis, laboratory results, and treatment notes.

This authorization is valid until: . I understand I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it.

I authorize the disclosure of my protected health information for treatment, payment, and healthcare operations as described above.
I acknowledge and authorize release of records as stated above.

HIPAA Privacy Acknowledgment

I acknowledge receipt of the practice's Notice of Privacy Practices and understand how my health information may be used and disclosed. I understand that I may request restrictions on certain uses and disclosures and that the practice will consider such requests in accordance with applicable law.

I acknowledge that I have received and reviewed the Notice of Privacy Practices.

Patient Certification

By signing below I certify that the information provided on this form is true and complete to the best of my knowledge. I consent to the evaluations and treatments checked above. I understand the risks, benefits, and alternatives have been explained and I have had the opportunity to ask questions. I accept financial responsibility for services rendered in accordance with the practice's policies.

If signed by a legal guardian or personal representative, state relationship to patient:

Sign Now