New Patient Questionnaire

Thank you for deciding to involve us in your care. We take great pride in the quality of care we offer and will continue to offer despite COVID 19. You will benefit from our no-touch home sleep testing and telemedicine. We are all in this together.

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. We work hard to respect your time and stay as close to schedule as possible. 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 then no-show, we may bill you $50. We make an effort not to have you come to clinic more than is necessary. At our discretion, we utilize phone visits and remote monitoring of data, which should save you time and money. Due to COVID-19, we no longer see patients for in person visits. Insurance companies have promised to reimburse for telemedicine services, but true coverage has been variable. If your insurance does not pay for telemedicine, we will offer a fair price for consultation following your sleep study.
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. By signing this form, I consent to telemedicine services. I can withdraw my consent at any time. At present, we are not conducting in person visits.
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. If you have such a plan, we suggest you contact a local academic center such as Penn, Temple, or Jefferson. 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.
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Sleep Questions


Sleep Questions

What have others said about things you do in your sleep?
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To what extent do each of the following apply?
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What upper airway issues have you had?
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These questions help us determine if you breathe through your mouth or nose while you sleep. Which of the following apply to you?
Some dental issues may influence how we address sleep and breathing disorders. Have you had any of the following dental issues?
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Insurance and Demographic Information


Insurance and Demographic Information

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The following information should be on your primary insurance card:
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The following information should be on your primary insurance card:
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The following information will most likely be on on your prescription card.
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Insurance Questionnaire


Insurance Questionnaire

Many insurance companies request that we ask these questions before seeking authorization for a home sleep test.
Which of the following describe your experience?
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 requires that we conduct a "review of systems." All of the following are fairly uncommon and if any are true, please contact your PCP. Constitutional:   negative for recent weight loss of 10 pounds or more Eyes:   negative for recent episode of blindness Ears/Nose/throat:   negative for bloody discharge from ears Respiratory:   negative for coughing up blood Cardiovascular:   negative for new chest pain Gastrointestinal:   negative for vomitting Genitourinary: negative for blood in urine Musculoskeletal   negative for new joint deformities Skin:   negative for new blistering Neurological:   negative for loss of concsiousness in past week Endo negative for excessive thirst Heme:   negative for frequent, unprovoked bleeding Allergies: negative for recent allergic reactions with difficulty breathing Psychiatric : negative for recent manic episode
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Additional Insurance Information


Additional Insurance Information

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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