Gender *
Male   Female     

Ethnicity
Hispanic   Non-Hispanic

Marital Status
Single   Married   Divorced   Widowed     

At least one phone number below is required *

(please make sure to spell name correctly)

Do you have Healthcare Insurance? *
Yes     No

Patient Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

 

Allergies to any medications or latex? *
Yes   No

Do you use blood thinners? Ex: aspirin, Coumadin/Warfarin, Plavix, Pradaxa? *
Yes   No

Please list any current or past health problems:

Yes   No   

Cardiac (eg: cholesterol, pacemaker, heart attack) *

Yes   No   

Hypertension or high blood pressure *

Yes   No   

Diabetes or uncontrolled sugar *

Yes   No   

Thyroid (eg: nodules, goiter, high or low function) *

Yes   No   

Allergies or hay fever *

Yes   No   

Hearing loss, ringing, or other hearing changes *

Yes   No   

Sinus or nasal problems previously diagnosed *

Yes   No   

Neurologic (eg: migraine, multiple sclerosis) *

Yes   No   

Stroke or TIA *

Yes   No   

Balance problems, BPPV, vertigo or dizziness *

Yes   No   

Pulmonary (eg: asthma, COPD, bronchitis) *

Yes   No   

Sleep apnea or CPAP use *

Yes   No   

Gastrointestinal (eg: acid reflux disease, IBS) *

Yes   No   

Psychiatric (eg: depression, anxiety, bipolar) *

Yes   No   

Cancer *

Yes   No   

Bleeding or blood clotting problems *

Yes   No   

Endocrine (eg: Cushing, PCOS) *

Yes   No   

Other (eg: arthritis, autoimmune disease) *

Do you use tobacco? *
Yes   No

Any past tobacco use? *
Yes   No

Do you drink alcohol? *
Yes   No

Any weight changes >10 lbs. this year? *
Yes   No

Do you exercise? *
Yes   No

Previous Head/Neck/Sinus or Ear surgeries? *
Yes   No

Please list ALL additional surgeries not entered above:

Add another?  

Tonsils Removed? *   
Yes   No

Adenoids Removed? *   
Yes   No

Click here to view our Notice of Privacy Practices.

I have received the Notice of Privacy Practices from Maryland ENT Associates, effective date 9/23/2013

Patient/Legal Representative Name

Patient Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

 

The Epworth sleepiness scale is used to help you Identify your own level of daytime sleepiness. Use the following scale to choose the most appropriate number for each situation: 0= Would never doze 1= Slight chance of dozing 2= Moderate chance of dozing 3= High Chance of dozing

Total score of 10 or more suggests wake-time sleepiness that may require a sleep evaluation to determine whether you are obtaining enough sleep or if you have an underlying sleep disorder. If your score is 10 or more please share this with your doctor.

Do you have a history of snoring? *
No - (0)
Mild/infrequent - (2)
Moderate/inconsistent - (3)
Severe/constant - (4)

Have you ever been told that you have “pauses” in breathing during sleep? *
No - (0)
Yes, but infrequent - (6)
Yes, inconsistent but most nights - (8)
Yes, severely so - (10)

Are you overweight? *
No - (0)
Yes, less than 20 lbs - (1)
Yes, 20-50 lbs - (2)
Yes, greater than 50 lbs - (4)

Epworth score from above: *
8 or less (0)
9 - 13 (3)
14 - 18 (5)
19 or over (8)

Does your medical history include:
High blood pressure (5)
Stroke (3)
Heart disease (3)
Morning headaches (2)
4 or more awakenings at night (2)
Excessive fatigue (2)
Depression (1)
Concentration problems (1)

Your apnea risk score suggests:

Discuss complaints with your doctor

A consultation with a sleep specialist is recommended

Sleep consultation and sleep study is recommended

Significant risk of sleep apnea – sleep study should be scheduled

This “Apnea Risk Score” is not intended to rule out the possibility of a sleep-related disorder. If you have concerns related to your sleep you should discuss them with your doctor.
 

Patient/Legal Representative Name

Do you experience any of these symptoms?
Runny Nose
Itchy Nose
Stuffy Nose
Itchy Eyes
Watery Eyes
Frequent Sneezing
Itchy Mouth / Lips / Throat
Post Nasal Drip (drainage down the back of the throat, clearing throat)

How often do you experience these symptoms?
Occasionally (2-3 times per year)
Over 3 times a year
A few long periods of time per year (Spring, Summer, Fall, Winter)
Most of the year

Do you take prescription or over-the-counter (OTC) medications for the management of your allergy symptoms?
Yes   No

Please indicate below symptoms/conditions you’ve experienced during the last 1 – 2 years
Sinus-related issues (sinus pressure/pain, headaches, sinusitis)
Recurring seasonal colds
Chronic colds (lasting longer than 2 months)
Migraine headaches
Restless sleep, challenges sleeping through the night, snoring
Consistent or recurring coughing
Feeling of fatigue, irritability or restlessness
Asthma
Skin conditions (dry and / or itchy skin, etc.)

I prefer to be contacted in the following manner (check all that apply):

OK to leave message with detailed information
Leave message with call-back number only

OK to leave message with detailed information
Leave message with call-back number only

OK to leave message with detailed information
Leave message with call-back number only

OK to mail to my home address
OK to mail to my work/office address

We respect your right to indicate who you prefer that we involve in your treatment or payment decisions and/or who we share your information with, including information about your general medical condition and diagnosis (such as treatment and payment options), access to medical records (PHI), prescription pick-up and scheduling appointments. Please note, however, that we may share your information as set forth in our Notice of Privacy Practices to other persons as needed for your care or treatment or the payment of services we have provided. Please update this information promptly if your preferences change.

Please indicate the person(s) you prefer we share your information with below:

Patient Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

 

Assignment of Benefits and Authorization to Release Medical Information. I hereby certify that the insurance information I have provided is accurate, complete and current and that I have no other insurance coverage. I assign my right to receive payment of authorized benefits under Medicare, Medicaid, and/or any of my insurance carriers to the provider or supplier of any services furnished to me by that provider or supplier. I authorize Privia to file an appeal on my behalf for any denial of payment and/or adverse benefit determination related to services and care provided. If my health insurance plan does not pay Privia directly, I agree to forward to Privia all health insurance payments which I receive for the services rendered by Privia and its health care providers. I authorize Privia or any holder of medical information about me or the patient named below to release to my health insurance plan such information needed to determine these benefits or the benefits payable for related services. I understand that if my insurance plan does not participate in the Privia network, or if I am a self-pay patient, this assignment of benefits may not apply.

Guarantee of Payment & Pre-Certification. In consideration of the services provided by Privia and its providers, I agree that I am responsible for all charges for services provided not covered by my health insurance plan or for which I am responsible for payment under my health insurance plan. I agree to pay all charges not covered by my health insurance plan or for which I am responsible for payment under my health insurance plan. I further agree that, to the extent permitted by law, I will reimburse Privia for all costs, expenses and attorney’s fees incurred by Privia to collect those charges.

If my insurance has a pre-certification or authorization requirement, I understand that it is my responsibility to obtain authorization for services rendered according to the plan’s provisions. I understand that my failure to do so may result in reduction or denial of benefit payments and that I will be responsible for all balances due.

Consent to Treatment. As a Privia patient, I voluntarily consent to the rendering of such care and treatment as Privia providers and personnel, in their professional judgment, deem necessary for my health and well-being.

If I request or initiate a telehealth visit (a “virtual visit’), I hereby consent to participate in such telehealth visit and its recording and I understand I may terminate such visit at any time.

My consent shall cover medical examinations and diagnostic testing (including testing for sexually transmitted infections and/or HIV, if separate consent is not required by law), including, but not limited to, minor surgical procedures (including suturing), cast application/removals and vaccine administration. My consent shall also cover the carrying out of the orders of my treating provider by care center staff. I acknowledge that neither my Privia provider nor any care center staff have made any guarantee or promise as to the results that may be obtained.

Consent to Call, Email & Text. I understand and agree that Privia may contact me using automated calls, emails and/or text messaging sent to my landline and/or mobile device. These communications may notify me of preventative care, test results, treatment recommendations, outstanding balances, or any other communications from Privia. I understand that I may opt-out of receiving such communications from Privia and its partners by notifying Privia at privacy@priviahealth.com, by informing my provider’s staff, or by visiting “My Profile” on my Privia Patient Portal.

HIPAA. I understand that Privia’s Privacy Notice is available at priviahealth.com/hipaa-privacy-notice/ and my care center’s website, and that I may request a paper copy at my care center’s reception desk.
 

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I hereby acknowledge that I have received Privia’s Financial Policy and Privia’s Notice of Privacy Practices. I agree to the terms of Privia’s Financial Policy, the sharing of my information via HIE,* and consent to my treatment by Privia providers. This form and my assignment of benefits applies and extends to subsequent visits and appointments with Privia providers.

Patient Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

 

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