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Follow Up Questionnaire

Thank you for continuing to involve us in your care.

Agreement with our Financial, Telemedicine, Privacy, and Scope of Practice policies


Agreement with our Financial, Telemedicine, Privacy, and Scope of Practice policies

Financial Policy of Brian Abaluck, LLC.
Copays are due at time of service. If you do not have insurance, please inform us, and we will offer a fair price for our services. If you are 15 minutes late for an appointment, then seeing you could cause all subsequent patients in a session to be seen late, so we may reschedule your visit. If you schedule an appointment and cancel without 24 hour notice, in the absence of COVID symptoms or a medical emergency, we will bill you $100. We may bill for any in person visits, any remote visits via zoom, and any phone calls.
Telemedicine Consent
I understand that telemedicine involves transfer of information, via voice and ideally via video, from one place to another. Dr. Abaluck's practice will not record the encounter, but any information gathered and placed in your medical record will be kept secure to the best of Dr. Abaluck's abilities. I confirm that I will be in the state of Pennsylvania at the time of the visit. By signing this form, I consent to telemedicine services. I can withdraw my consent at any time.
Privacy Policy of Brian Abaluck, LLC.
We aim to keep your medical records safe. We will never sell your information. However, we do share information, for example, with your primary doctor, other doctors you wish to see our notes, care coordination networks in which we participate, and our billing agency. We detail how we use your information in our Privacy Policy. You may obtain our detailed Privacy Policy by requesting a copy from us at 462 east king rd, suite 1, Malvern, pa or at 484-888-0091. Dr. Abaluck, our privacy officer, can be reached at this address and phone number as well with any privacy concerns.
Scope of Practice Policy of Brian Abaluck, LLC
This practice treats only sleep disorders. Sleep disorders may contribute to neurological disorders, and we may discuss these links if you have a known neurological disorder. That said, among new patients, we do not evaluate or treat neurological disorders including but not limited to headache, memory loss, unsteadiness, seizures, numbness, weakness, vertigo, neuropathy, or pain. If we find evidence of a neurological disorder on history or exam, we can provide a referral. Please note that Brian Abaluck, LLC is not a Medicaid provider. We do not provide services to patients who have Medicaid/state assistance plans. Medicaid/state assistance plans include Aetna Better Health, Health Partners, Keystone First, and United Community Plan. We are not accepting new patients with Aetna Medicare or Aetna Commerical. If you have such a plan, we suggest you contact a local academic center such as Penn, Temple, or Jefferson. Traditional Medicare with Aetna supplement is accepted. By signing below, I authorize Brian Abaluck, LLC to use health information about me (or the patient for whom I sign) for treatment, payment, and health care operations purposes as detailed in our Privacy Policy. I understand and accept the scope of Dr. Abaluck’s practice. I also confirm that I have read, understand, and agree to the financial policy of Brian Abaluck, LLC.
Home Sleep Study Device Return
We often use home testing to assess breathing during sleep. Home testing saves you money, time, and risk. Devices are provided for 1 night only. If you borrow a device, we ask that you act responsibly in returning the device, so others are not delayed. You, or a spouse, commit to returning this device immediately after your study ends. Please return the device as early as you can, NO LATER THAN 4 PM on the day after you borrow the device. If you do not return the device on time, another patient may show up and find that no device is available. For each day you are late returning the device, we may bill you $50. If you do not return the device, or if you break the device, we may bill you the full $3000 cost of the device.
Agreement with our Financial, Telemedicine, Privacy, and Scope of Practice policies:
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You can initiate zoom from https://brianabaluck.zoom.us/my/sleep - this link will prompt download of the zoom app if not installed. I you are a veteran zoom user, note our Zoom ID of 825 346 5429. We no longer use Facetime. Please plan to join 10 minutes before the visit. If you anticipate needing help with zoom, please call us at 484-888-0091.
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Return visit questions


Return visit questions

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Please answer each of the following questions on a scale of 0 to 3, indicating your likelihood of dozing in each situation. 0- would never doze. 1- slight chance of dozing. 2- moderate chance of dozing. 3- high chance of dozing. N/A- I do not routinely do this, so I can't really provide a number.
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Insurance Information


Insurance Information

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In HMO plans, your primary doctor must place a referral in a particular computer system- "navinet" or "availity"- for you to see a specialist or obtain any study. If your primary care doctor does not place a referral, you are responsible for any costs associated with testing. Your primary doctor may provide you a referral number to confirm that a referral has been placed. The referral would be for a home sleep test, cpt code g0399. Dr. Abaluck's group NPI is 1962834077.
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Insurance and Address Change


Insurance and Address Change

Complete the following section only if your address or insurance has changed from when we last saw you.
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