What s the name of your position?

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3 What s the name of your position? What are some basic work responsibilities (e.g primarily front desk/administration, light lifting or heavy liftingplease indicate pounds)?

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5 CONSENT FORM FOR USE AND DISCLOSURE OF HEALTH INFORMATION With my consent, Dr. Spence or his designee, may use and disclose protected health information about me to carry out treatment, payment and healthcare operations. Please refer to our Notice of Privacy Practices for a more complete description of such uses and disclosures. I have the right to review the Notice of Privacy Practices prior to signing this consent. We reserve the right to revise the Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to the Practice Privacy Officer at:. Name of Privacy Officer: Practice: Address: City, State, Zip. Sharon Jones Caple Spence, M.D National Avenue, Suite 210 Midwest City, OK Telephone Please circle Yes or No With my consent, Dr. Spence or his designee may call my home or another designated location and leave a message (on voic , answering machine or in person) in reference to any items that assist the practice in carrying out treatment, payment and healthcare operations. This may included appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory and other results. 2. Mail Please circle Yes or No With my consent, Dr. Spence or his designee may mail to my home or another designated location any items that assist the practice in carrying out treatment, payment and healthcare operations such as appointment reminder cards, correspondence and billing statements. 3. Please circle Yes or No With my consent, Dr. Spence or his designee may any items that assist the practice in carrying out treatment, payment and healthcare operations, correspondence and billing statements. Please request any specific restriction(s) you may have to the use and/or disclosure of your health information: We may release your health information to other physicians, medical facilities and health insurance companies who are providing your medical care and health coverage. NOTE: If there are additional individual(s) and/or organizations(s), you must list them below or we will not be able to release any information to them. Spouse: Other family: Other: I have the right to request that Dr. Spence or his designee restrict the use or disclosure of my protected health information to carry out treatment, payment and healthcare operations. (Please request form.) I understand that the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form, I consent to the use and disclosure of my protected health information to carry out treatment, payment and healthcare operations by Dr. Spence or his designee. I may revoke my consent in writing to the extent that the practice has already made disclosures based upon my prior consent. If I do not sign this consent, Dr. Spence may decline to provide treatment to me. Your signature below will verify your consent of above information and that you have received a copy of our Private Policy. Signature of Patient or Legal Representative Date signed

6 Epworth Sleepiness Scale Patient: Date: The Instrument How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to you usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation: 0 = No chance of dozing 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozing Situation Chance of dozing Sitting and reading Watching TV Sitting inactive in a public place (e.g a theater or meeting) As a passenger in a car for an hour without a break Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone Sitting quietly after a lunch without alcohol In a car, while stopped for a few minutes in traffic Total Have you ever had a sleep study before Do you wear a CPAP machine Have you ever been told you have sleep apnea

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