Our staff will need to make a photocopy of the following: Insurance Card (front and back) Driver's License or picture identification

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Long Island Pulmonary and Sleep Medicine Associates, PLLC Louis Saffran, MD FCCP Frank S. Coletta, MD FCCP Karen Mrejen-Shakin, MD FCCP Aviva Kamath, MD FCCP Sepideh Sedgh DO 200 North Village Avenue Suite 300 Rockville Centre, NY 11570 Tel 516-536-8151 Fax 516-536-8153 Our staff will need to make a photocopy of the following: Insurance Card (front and back) Driver's License or picture identification Primary Insurance Carrier Name: Policy#: Group#: Name of Policy Holder: Date of Birth: SSN of Policy: Relation to Patient Secondary Insurance Carrier Name: Policy#: Group# Name of Policy Holder: Date of Birth: SSN of Policy: Relation to Patient Signature: Date:

MEDICAL HISTORY Page 1 of 2 Name: Date: List any Drug Allergies: HAVE YOU EVER SMOKED: YES NO STILL SMOKING? YES NO YEAR QUIT IF YES: Cigarettes Per Day # of Years ALCOHOL: YES NO Oz. Per Week Coffee/Tea: YES/NO Cups Per Day FAMILY HISTORY YEAR OF IMMUNIZATION High Blood Pressure Heart Disease Epilepsy Hepatitis Mumps Diabetes Cancer Kidney Disease Pneumonia Rubella Asthma Hay Fever Migraine Flu Polio Glaucoma Stroke Bleeds Easily Tetanus Mental Illness Alcoholism Eczema Diphtheria Anemia Psoriasis Measles HOSPITAL ADMISSION Indicate the year you were admitted into the hospital and the reason. Do Not include normal pregnancies. Year Illness or Operation Year Illness or Operation MEDICATIONS List all medications that you are currently taking, including over the counter drugs. Medications Strength How Often medication Strength How Often

MEDICAL HISTORY Page 2 of 2 MEDICAL HISTORY Check all that apply. Decreased hearing Blood in stool Glaucoma Freq. Urine infections Numbness/tingling Asbestosis Ringing in Ear Venereal Disease Cataracts Blood in urine Constipation Emphysema Freq. Ear infections Hepatitis Difficulty swallowing Control of urination Diverticulitis Abnormal X-ray Dizzy spells Chest pain Indigestion/Heartburn Decreased force in urine Bronchitis/chronic cough Pulmonary Fibrosis Measles High blood pressure Loss of appetite Kidney Disease Gall bladder trouble Narcolepsy Failing vision Swollen ankles Freq. Nausea/vomiting Chronic fatigue Back pain-recurrent TB Double/blurred vision Moodiness Peptic ulcers Recent weight loss Shortness of breath Asthma/Wheezing Freq. Eye infections Heart murmur Chronic abdominal pain Anemia Foot pain Mumps Nose bleeds Irregular pulse Change in bowel habits Bruise easily Cold numb feet Polio Freq sore throat Palpitations Diarrhea Cancer Rashes German measles Hay fever Fainting spells Pneumonia/pleurisy Thyroid disease Hives Rheumatic fever Allergies Kidney stones Hernia Diabetes Difficulty sleeping Restless Leg Syndrome Hoariness prolonged Leg pain when walking Arthritis Convulsions/seizures Nervousness Gout freq. headaches Varicose veins Jaundice Stroke Depression COPD Hemorrhoids Phlebitis Bone fracture/joint injury Tremor/Hands shaking Memory loss Sleep Apnea Signature: Date

Long Island Pulmonary and Sleep Medicine Associates, PLLC Louis Saffran, MD FCCP Frank S. Coletta, MD FCCP Karen Mrejen-Shakin, MD FCCP Aviva Kamath, MD FCCP Sepideh Sedgh DO 200 North Village Avenue Suite 300 Rockville Centre, NY 11570 Tel 516-536-8151 Fax 516-536-8153 AUTHORIZATION TO DISCLOSE HEALTH INFORMATION I authorize Long Island Pulmonary and Sleep Medicine Associates, PLLC to discuss my health information with the following personal representative(s) Name: Relationship: Name: Relationship: Name: Relationship: Name: Relationship: It is the policy of Long Island Pulmonary and Sleep Medicine Associates, PLLC to confirm appointment via telephone. Home Telephone Cell Phone OK to leave message with detailed information* Leave message with call back number only Written Communication OK to mail to my home address Ok to leave message with detailed information* Leave message with call back number only Work Telephone Ok to leave message with detailed information* OK to mail to my work/office address(provide address) Leave message with call back number only OK to fax to this number Other: Patient Name: DOB: Patient Signature Date * detailed information may include but is not limited to: lab results, diagnosis and/or treatment instructions. PLEASE NOTE: THE ABOVE INFORMATION WILL BE IN EFFECT UNTIL YOU REVOKE IT.

Long Island Pulmonary and Sleep Medicine Associates, PLLC Louis Saffran, MD FCCP Frank S. Coletta, MD FCCP Karen Mrejen-Shakin, MD FCCP Aviva Kamath, MD FCCP Sepideh Sedgh DO 200 North Village Avenue Suite 300 Rockville Centre, NY 11570 Tel 516-536-8151 Fax 516-536-8153 ACKOWLEDGEMENTOF RECEIPT OF LONG ISLAND PULMONARY AND SLEEP MEDICINE ASSOCIATES, PLLC I acknowledge that I have received a copy of Long Island Pulmonary and Sleep Medicine Associates, PLLC's Notice of Privacy Practices. PATIENT CONSENT I hereby give Long Island Pulmonary and Sleep Medicine Associates, PLLC, its physicians and staff, my consent to release my protected health information as needed in connection with my care and treatment. I understand that under HIPAA regulations my consent is not necessary for Long Island Pulmonary and Sleep Medicine Associates, PLLC, its physicians and staff, to release my protected health information for purposes related to my treatment, payment for my treatment, and healthcare operations. MEDICAL CLAIMS INSURANCE UNDERSTANDING AND CONSENT I understand and agree to the following: Should the physician participate with my medical insurance carrier, I am responsible for any and all co-payments, coinsurance, and deductible amounts. I am responsible for all charges incurred should I fail to obtain any necessary referral/ authorization as required by my insurance carrier. Should the physician not participate with my medical insurance carrier, I am responsible for full payment of all charges incurred. I consent to the release of any of my protected health information necessary to process medical claims for professional services rendered to me. MEDICARE ASSIGNMENT OF BENEFITS I request that payment of authorized Medicare benefits be made either to me or on my behalf to Long Island Pulmonary and Sleep Medicine Associates, PLLC for services furnished to me by the provider. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for related services.

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