New Patient Questionnaire

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.

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.

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.

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.

You have the following rights: 1. The right to accurate and easily-understood information proposed about the patient’s health care and the providers of such care. If the patient speaks another language, has a physical or mental disability or just doesn’t understand something, help should be given so that the patient can make informed health care decisions. 2. The right to know treatment options and take part in decisions about care. Parents, guardians, family members, or others can speak for the patient, if the patient cannot make his/her own decision. 3. The right to considerate, respectful care from your doctors and other health care providers that does not discriminate against the patient. 4. The right to talk privately with health care providers and to have health care information protected. 5. When needed, we may conduct and bill insurance for remote monitoring of devices and remote care management of a principal sleep disorder or of multiple sleep disorders. As with most services, there is a possibility of patient cost-sharing for these services . You may choose to stop remote management of sleep disorders or remote monitoring of any devices at any time. 6. The right to read and copy your own medical record, and the right to ask that your doctor change the record if it is not correct, relevant or completed. 7. The right to examine and receive a detailed explanation of any medical bill, and the right to information regarding financial assistance the practice may offer.

We may conduct and bill insurance for services including, but not limited to, sleep studies, clinic visits (remote, in person, and for medicare, phone visits), remote monitoring of devices, and management of complex disorders.

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.

Have others seen you acting out your dreams at night?

To what extent do each of the following apply?

What upper airway issues have you had?

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?

The following information should be on your primary insurance card:

Which of the following describe your experience?