c ente r Wel c ome to Alpine Sleep D i s orde r s C e nte r

alpin e sleep disorders c ente r Wel c ome to Alpine Sleep D i s orde r s C e nte r Dear valued nt, You have been referred to Alpine Sleep Disorders Center for an overnight sleep study. We have contacted your insurance company to obtain benefits and authori on. If your insurance changes please no fy us 24 to 48 hours prior to your sleep study. Enclosed you will find some ent info on that will help familiarize you with sleep studies and how we operate. If you have any que er reading the material, we will be happy to answer them for you by telephone prior to your appointment. Also enclosed is a Sleep Ques onnaire form. Please complete this info on and bring it with you to your appointment. This informa on is important and necessary for the physician to accurately diagnose and treat your sleep and health concerns. We appreciate you sele g Alpine Sleep Disorders Center and will work hard to serve your needs. As an accredited sleep center by the American Academy of Sleep Medicine you can feel confident that your sleep study will be conducted by trained personnel who uphold the highest standards in sleep medicine. Your appointment is scheduled for: Date: Time: P.M. Loca on: with less than 24 hours no ce will be charged a $100.00 cance on fee** Sincerely, Alpine Sleep Disorders Center American Fork 52 North 1100 East, American Fork, UT 84003 Orem 498 E 800 N Suite 3B, Orem, UT 84057 Payson n: 41 North 400 West, Payson, UT 84651 Phone: (801) 492-6587 Fax: (801) 221-4656

alpine sleep disorders center What to expect: Preparations: Alpine Sleep Disorders Center A guide to your sleep study and our sleep center The hook-up procedure takes approximately one hour so please come to the Sleep Lab on time. If your appointment is scheduled for our Orem or American Fork office you may need to ring the buzzer or doorbell to the right of the entrance if the door is locked. A sleep technician will let you in. Please remember that both the CPAP and Polysomnogram are full-night studies. You will be unhooked the next morning between 6:00 and 6:30 am. There are many different things that your sleep study will monitor. Wires will be pasted to your head to monitor brain waves. Some of the reasons we use the wires are to find out how long it takes for you to fall asleep, how much of the night you are able to maintain sleep, what stage of sleep you are in, and how often you arouse / awaken during the night. We will use belts and an airflow sensor to monitor your breathing in order to see if you stop breathing during the night, how often this happens, and for how long. Your heart rate will be monitored as well as your blood oxygen levels. You will have wires attached to your legs and to your chin to monitor muscle tone and muscle movement during your study. The wires and monitors will be worn throughout the entire study. You will not be given any shots or injections. We would like you to follow your normal bedtime routine as closely as possible. This will help you fall asleep more easily and feel more comfortable during your study. Don t worry if you can t fall asleep right away. We understand that it is harder to fall asleep or sleep as long when you are in an unfamiliar setting. Just try to get some rest. After you are ready for bed and the lights are out, you will be monitored by a trained technician who will sit in an adjacent room. Remember that the technician is not a doctor or a nurse. Any information you would like your doctor to have needs to be written in the questionnaire you will be asked to fill out. In the case of a medical emergency, the technician will call the doctor on call. You may either wear comfortable clothes to the study or bring clothes to change into. Whatever you sleep in should be a two-piece outfit that is somewhat loose fitting so the technician can place leg and ECG electrodes easily. Please come with clean, dry hair with no gel, mousse, or hairspray, and without any make-up or lotion on your skin. Avoid caffeine (soda, coffee, or chocolate) and alcoholic beverages for 24 hours before your test. Avoid smoking cigarettes the afternoon before your test.

If at all possible, do not take a nap the day of your sleep study. Take all of your routine medications the day of your study, and be sure to bring enough for your evening, morning, and midnight doses, if any. Sorry, there isn t a place for your husband or wife to sleep during the test. If you are given a ride, please have them return between 6:00 and 6:30 am the next morning. A cable or satellite television is provided. You may bring reading material or other hobbies to help you relax and fall asleep. If you have a favorite pillow or blanket, please bring it. Polysomnogram: The test will check for sleep apnea or other possible sleep disorders. You will undergo the basic hook up (as described on the previous page. You may also be scheduled for a split night study that, if protocols are met (significant apnea accompanied by oxygen desaturation early in the night) a CPAP study will be performed the second half of the night. CPAP Study: A CPAP study is a Polysomnogram that includes hook up to a CPAP machine for positive airway pressure treatment that will provide therapeutic levels of air flow (not oxygen) throughout the study in order to treat apneic events. This study will include the basic hook up and monitors (as described on the previous page) as well as the use of a CPAP machine delivering airflow through a CPAP mask. Your technician will explain the process and assist you in adjusting to the machine and finding a comfortable mask. Throughout the study, the CPAP setting will be increased or decreased to find a suitable air flow pressure that will treat your sleep apnea. MSLT (Multiple Sleep Latency Test): This test evaluates for Narcolepsy and EDS (excessive daytime somnolence) and may accompany a Polysomnogram. Your hook up will be similar to the one described above. Be sure to bring something to eat for breakfast and lunch, as the test will last all day. Bring any medications you would normally take during the day unless instructed otherwise. We don t want to disrupt your daily/nightly regimen. Our sleep technician should inform you of what time the test will be ending. If they don t please ask them. Results: It can take up to two weeks to get the results of your study (In most cases results are ready within 4 5 business days). We will call to let you know the results of the study and the doctor s recommendations. We will also fax or mail a copy of the test to your referring physician. If your Polysomnogram has indicated that you have sleep apnea you may be scheduled for a CPAP study at the time we notify you of your results.

Neurological Associates Financial and Service Agreement I understand the office of Neurological Associates utilizes the following billing procedures: 1) An insurance claim will be sent to my HMO or other insurance soon after services are provided, detailing the date of services provided, diagnoses, and charges. In the event that I have not provided adequate information to bill my insurance company, I can expect to receive a bill for the services provided. In the event that the information I have provided is incorrect, Neurological Associates may not back bill my claim. I will be responsible for the charges and can expect to receive a bill. 2) Neurological Associates should receive an Explanation of Benefits from the HMO and/or other insurance detailing my portion of the bill. After the insurance company has responded to the claim from Neurological Associates, I will receive a bill for my portion of the bill. If no amount is due, I may not receive a notice. 3) Neurological Associates collects co payments at the time of service. Due to the high cost of statements, I agree to pay a $7.00 service fee if I fail to pay my co payment at the time of service. I also agree to be fully responsible for the following charges, services, and actions on any delinquent amount I am responsible for: a. Account must be paid within 90 days or a finance charge of $7.00 will be added to my account monthly. b. 33 % of the delinquent amount will be added if my account goes to collections. c. Collection and legal fees of 50 % of the total amount will be added if sent to collections. d. I will be terminated from the practice of Neurological Associates for failing to pay for services provided. Neurological Associates will notify me of this action with a letter in the mail and will assist as necessary until another provider can be located. I understand that I am financially responsible for amounts that are designated as my responsibility by my HMO or other insurance member contract. Such amounts are computed on the Explanation of Benefits (EOB) and may include co payments, co insurance or deductible amounts. Any co payments, co insurance or deductible amounts are my responsibility under the insurance member contract and are due and payable to Neurological Associates at the time of service. I also understand that I am responsible to pay Neurological Associates the usual and customary, or otherwise reasonable fees (as determined by Neurological Associates) for any service rendered that is not defined by my insurance provider as being covered by Neurological Associates. In the case that my provider deems me ineligible Continued on next page

for services rendered by Neurological Associates, I understand that I am responsible for those charges. I understand that if at any time I do not have insurance coverage and receive services from Neurological Associates I am responsible to pay for the services provided. I also understand that in the course of my evaluation and treatment, medical treatment and neurological testing may be ordered and done. Such testing may be expensive and may not be covered or completely covered by my insurance. I understand that I am ultimately responsible for these costs. Neurological Associates reserves the right to charge a reasonable fee determined by Neurological Associates for medical records, forms completion, letter writing, failing to appear at my appointment without proper notice, and late cancellations. I authorize the release of my medical information by Neurological Associates as necessary for treatment, payment and operations, and in compliance with HIPAA regulations. Neurological Associates requires 24 hours notice for cancellations of appointments. Neurological Associates requires 72 hours notice for prescription refills. Neurological Associates requires up to 30 days notice to provide medical records, completed forms, and letters. I understand that I am responsible to follow up with the office to receive test results. Neurological Associates maintains a tight schedule in order to serve many patients while still allowing for adequate time to see them. I understand that if I show up more than fifteen minutes late for my appointment I may be required to reschedule and be charge a late cancellation fee. Appointments are scheduled and pre authorization is obtained as a courtesy to me. Ultimately I understand that I am responsible to know which providers, services, and locations I may or may not utilize, i.e. I am responsible to know which services are covered by my insurance, if my provider is contracted with my insurance and if the facilities in which I receive services are contracted. I have read and understand the above terms and conditions, and hereby agree to abide by all terms and conditions as outlined by the financial agreement. Patients or Guarantors Signature Date

NEUROLOGICAL ASSOCIATES Christopher J. Reynolds, M.D. Mohammad Entezari Taher, M.D RECEIPT OF WRITTEN NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGEMENT FORM I, have been given the opportunity to read or have received a copy of Neurological Associates Notice of Privacy Practices. Signature of Patient or Legal Guardian Patient s Name PATIENT CONSENT With my consent, Neurological Associates may use and disclose protected health information (PHI) about me to carry out treatment, payment, and healthcare operations (TPO). Please refer to Neurological Associates Notice of Privacy Practices for a more complete description of such uses and disclosure. I have the right to review the Notice of Privacy Practices prior to signing this consent, and may request a hard copy of the Notice of Privacy from the receptionist. Neurological Associates reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Neurological Associates Privacy Officer at 52 North 1100 East, American Fork, Utah 84003. With my consent, Neurological Associates may call my home or other designated location and leave a message on voice mail or in person in reference to any item(s) that assist(s) the practice in carrying out TPO, such as appointment reminders, insurance items, and any call pertaining to my clinical care, including laboratory results among others. With my consent, Neurological Associates may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. With my consent Neurological Associates may e mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Neurological Associates restrict how it uses or discloses my PHI to carry out TPO. However, 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 am consenting to Neurological Associates use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practive has already made disclosures in reliance upon my prior consent. If I do not sign this consent, Neurological Associates may decline to provide treatment to me. Patient s Name Signature of Patient or Legal Guardian Date

Sleep Disorder Questionnaire Name: Age: Date: Main Complaints: Height: Weight: Neck Circumference: Please circle if you have any of the following medical problems: Hypothyroidism Heart Failure Hypertension Asthma Chronic Bronchitis Emphysema Renal Failure Parkinson Disease Alzheimer disease Epilepsy Seizures Multiple Sclerosis (MS) Anxiety Depression Bipolar Schizophrenia Chronic Pain Arthritis Fibromyalgia Migraines Diabetes Gastric Reflux Sinus Disease Allergies Sleep Apnea Narcolepsy Restless Legs Insomnia Please list any additional medical problems that you have been diagnosed with: If you have Sleep Apnea, do you currently use a CPAP or BiPAP machine? Yes No If yes, what is the current setting? Do you use oxygen at night? Yes No If yes, what is the current oxygen setting? List any medications you take (include over the counter medications, stimulants, vitamins, and herbs). You do not need to list the medication dose or schedule. The following questions concern additional substances that can affect sleep: If you use any caffeinated drinks please indicate how much per day or week: Coffee: cups per: DAY WEEK (check one) Soda: cans or bottles per: DAY WEEK (check one) What time do you drink your last caffeinated beverage before bed?

If you drink alcohol please indicate how much: Beer: cans or bottles per: DAY WEEK MONTH (check one) Wine: glasses per: DAY WEEK MONTH (check one) Liquor: drinks per: DAY WEEK MONTH (check one) What time do you have your last alcoholic drink before bed? Do you smoke? Yes No If yes, how many cigarettes in a day? Do you use or have you recently used non-prescribed or recreational medications such as Marijuana, Cocaine, or Amphetamine? Yes No If so, please list: Do you have a family history of (check all that apply): Snoring Sleep Apnea Narcolepsy Restless Legs Insomnia The following questions ask you to describe your sleep patterns: What time do you go to bed? pm am How long does it take you to fall asleep? minutes hours How many times do you wake up from your sleep? times What wakes you up during your sleep? If you wake up during your sleep, do you have difficulty falling back to sleep? Yes No What time do you wake up? am pm What time do you get out of bed? am pm Please answer the following Yes/No questions: Yes No Y N Have you ever been told that you snore? Y N Have you been told that you stop breathing at night? Y N Do you ever wake up in the night short of breath or choking? Y N Do you have trouble breathing through your nose? Y N Do you wake up in the morning with headaches? Y N Do headaches wake you up at night? Y N Do you wake up with heartburn? Y N Do you wake up coughing? Y N Do you wake up wheezing? Y N Do you wake up with a sore throat? Y N Are you sleepy during the day? Y N Do you find yourself falling asleep without meaning to? Y N Have you ever had an automobile accident due to sleepiness? Y N Have you ever had a near accident due to sleepiness? Y N Do you wake up in the morning tired? Y N Do you take naps during the day? If yes, how many times per week? How long are they? Y N Do you have problems with your memory or concentration? Y N Do you ever wake up at night confused?

Y N Are you having mood swings? Y N Have you had any changes in your personality/attitude? Y N Do you have restless legs or irritating sensations in your before you go to sleep? Y N If you have restless legs before sleep, does walking or moving around help relieve them? Y N Have you been told that you kick or twitch your legs at night? Y N Do you have violent movements in your sleep? Y N Do you ever experience episodes of muscular weakness during the day? Y N Do you collapse for no reason? Y N Does anything special trigger your weakness or collapses? If yes, please explain: Y N Do you ever experience sleep paralysis when falling asleep? (Sleep Paralysis is a sensation of not being able to move, even though you are awake, and can be associated with fear or anxiety) Y N Do you have hallucinations in your sleep? Y N Do you have nightmares? If yes, How frequently do you have nightmares? Y N Do you sleep walk? Y N Do you wake up in the morning with headaches? Y N Do you wake up during the night with headaches? If yes, Please describe: Y N Do you fall to sleep with (check all that apply): Lights On TV Reading Y N Do you snack and/or drink when you wake up at night? Y N Do you get better sleep (check all that apply): While on Vacation In a hotel room While in your own bedroom Y N Do you try hard to sleep while in bed? Y N Are you losing your sex drive? Y N (men only) Do you wake up with an erection in the morning? Y N (men only) Are you having painful erections in your sleep? Y N Do you have difficulty initiating sleep? Y N Do you have difficulty maintaining sleep? Y N Do you believe you have Insomnia? If yes, Please describe what treatments you have had: Y N Is your bed comfortable for sleep? Y N Are there things in your bedroom that disrupt your sleep? If so, please list what disturbs your sleep (e.g. snoring, moving bed partner, pets, noises, too much light, etc.) Y N Is your sleep period later than what you need it to be? Y N Is your sleep period earlier than what you need it to be? Y N Do you have problems with Jet Lag?

EPWORTH SLEEPINESS SCALE (ESS) INSTRUCTIONS: Rate the chance that you would doze off or fall asleep during different routine daytime situations. How likely are you to fall asleep in contrast to just feeling tired? Use the following scale to choose the most appropriate number for each situation. ESS Scale: 0 = would never doze 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozing Situation Chance of Dozing (0 3) Sitting and reading Watching Television Sitting in a public place (i.e., meetings theater, etc.) As a passenger in a car for an hour or more without a break Lying down in the afternoon for a rest Sitting and talking to someone Sitting quietly after lunch In a car, while stopped in traffic Total

alpine sleep disorders center ***DRIVING INSTRUCTIONS FROM I-15*** TO OUR OREM LOCATION: 1) TAKE I-15 TO THE 800 NORTH OREM EXIT (EXIT 272) AND HEAD WEST 2) CONTINUE EAST ON 800 NORTH FOR 0.7 MILES 3) TURN LEFT ONTO 800 WEST 4) TAKE AN IMMEDIATE RIGHT 5) END AT ALPINE SLEEP DISORDERS CENTER CONNECTED TO THE TIMPANOGAS HOSPITAL. IT IS IN THE PHYSICIAN OFFICE BUILDING, 700 WEST 800 NORTH-SUITE 330, OREM, UT 84057 TO OUR AMERICAN FORK LOCATION: 1) TAKE I-15 TO THE 500 EAST AMERICAN FORK EXIT (EXIT 276) AND HEAD NORTH 2) CONTINUE NORTH ON 500 EAST FOR 0.9 MILES 3) TURN RIGHT ONTO STATE STREET 4) CONTINUE EAST ON STATE STREET FOR 0.9 MILES UNTIL YOU REACH 1100 EAST (2 ND STOP LIGHT) 5) TURN LEFT ON 1100 EAST 6) CONTINUE ON 1100 EAST FOR 0.4 MILES. 7) END AT ALPINE SLEEP DISORDERS CENTER, 52 NORTH 1100 EAST, AMERICAN FORK, UT 84003 TO OUR PAYSON LOCATION: 1) TAKE I-15 TO THE PAYSON EXIT (EXIT 250) AND HEAD SOUTH ONTO MAIN STREET 2) CONTINUE HEADING SOUTH ON MAIN STREET FOR 0.8 MILES 3) TURN RIGHT (WEST) ONTO STATE RD (100 NORTH). THIS ROAD WILL CURVE LEFT. TURN RIGHT ONTO UTAH AVENUE AFTER 0.2 MILES 4) CONTINUE ON UTAH AVENUE FOR 0.2 MILES. 5) END AT ALPINE SLEEP DISORDERS CENTER 41 NORTH 400 WEST, PAYON, UT 84651.