ARIZONA PREMIER PULMONARY & SLEEP SPECIALISTS

(602) 978-6100 Fax: (602) 978-6555

Pulmonary Disease - Sleep Medicine/Polysomnogram Interpretation - Critical Care Medicine

Fiber-optic Bronchoscopy - Pulmonary Function Testing – Cardiopulmonary Exercise Testing

Pulmonary Disability Evaluation-Valley Fever Clinic

MANJIT S. BHAMRAH, M.D., F.C.C.P.

Diplomate of American Board of Pulmonary & Sleep Medicine

SALAM RAFIQUE, M.D.

Diplomate of American Board of Pulmonary Medicine

OUR LOCATION:

13606 N. 59TH

AVENUE #1, GLENDALE, AZ 85304

LOCATED 1 BLOCK SOUTH OF THUNDERBIRD RD ON THE SOUTHWEST CORNER OF 59th

AVENUE & EUGIE.

ARIZONA PREMIER PULMONARY & SLEEP SPECIALISTS PATIENT REGISTRATION

Responsible Person’s Information

First Name: MI: Last Name: Sex: M F

Birth Date: Social Security#: Relation to Patient:

Insurance Information Primary Insurance: ID#: Group#:

Policyholders Name: Sex: M F DOB: Relation to Patient:

Secondary Insurance: ID#: Group#:

Policyholders Name: Sex: M F DOB: Relation to Patient:

Emergency Information (*PLEASE PROVIDE CONTACT INFORMATION*) Emergency Contact Name: Emergency#: ( )

Address: Relation to Patient:

ADVANCE DIRECTIVES: DO YOU HAVE A LIVING WILL? YES NO IF NOT, WOULD YOU LIKE INFORMATION ABOUT A LIVING WILL? YES NO

IF YOU HAVE A LIVING WILL, MAY WE HAVE A COPY TO FILE IN YOUR CHART? YES NO (STAFF INITIALS: _________) PLEASE CONTACT ME AT: HOME PHONE WORK PHONE OTHER_______________________________________________

I hereby assign my insurance benefits to be paid directly to the physician for services rendered. I understand that I am financially

responsible for any non-covered services, co-insurances, or deductibles, including any balance of my account until the insurance pays their portion. If my insurance pays me directly for services provided by the physician, I agree to forward such payments to Paseo Medical Specialists, dba Arizona Premier Pulmonary & Sleep Specialists. I understand that it is my responsibility to notify this office of any changes in

the above information. I also authorize the physician to release any information required to process this claim. In the event that any unpaid balance should be forwarded to a collection agency, I understand that I will be fully responsible for any and all costs. I also

understand that my protected health information (PHI) will not be released in any form without my written consent, as described in this office’s privacy and confidentiality policy. I understand that I have a right to a copy of this policy at any time, and that any requests for

access to or copies of my PHI must be made in writing. I also understand that it is the policy of this office to give at least 72 hours notice prior to receiving requested PHI information, and that I may be charged a nominal copying fee for any records requested for my personal use. I also understand that any previous account balances must be paid in full prior to the release of any records, to any entity, myself

included. Charges for minors will be the responsibility of the signer below.

SIGNATURE: ___________________________________________________________________________________DATE: __________-_________-__________

(PATIENT OR LEGAL REPRESENTATIVE) Revised August 15, 2014

Last Name: First Name: Middle Initial: Name you prefer to be called:

Mailing Address: City: State: Zip Code:

Street Address: City: State: Zip Code:

Home Phone#: ( ) Cell Phone#: ( ) Work Phone#: ( )

Birth Date: Social Security#: Sex: M F

Marital Status: Single Married Divorced Separated Widowed

Employment Status: Full Time Part Time Retired Unemployed Disable d Student

Race: White Hispanic Black Native American Asian Other: Primary Language Spoken:

Primary Care Physician: Referred By: E -Mail Address:

WHO IS THE PRIMARY CONTACT PERSON REGARDING CARE? PATIENT OTHER Name of contact:

REVISED 08/14

ARIZONA PREMIER PULMONARY AND SLEEP SPECIALISTS

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I, (Please print name) ___________________________________________ , acknowledge and agree that I have received a copy of Paseo Medical Specialists, dba Arizona Premier Pulmonary & Sleep Specialists Notice of Privacy Practices.

Patient Signature Date Patient Legal Representative (if applicable) Date

Print Name of Legal Representative Date

FOR CLINIC USE ONLY:

Paseo Medical Specialists, dba Arizona Premier Pulmonary & Sleep Specialists, made the following good

faith efforts to obtain the above-referenced individual's written acknowledgement of receipt of the Notice of Privacy Practices:

(Identify the efforts that were made to obtain the individual's written acknowledgement, including the reasons (if known) why the written acknowledgement was not obtained)

Notice of Privacy Practices given at time of appointment

Notice of Privacy Practices sent with new patient paperwork prior to appointment

Other: ______________________________________________________________________________________

ARIZONA PREMIER PULMONARY & SLEEP SPECIALISTS 13606 N. 59TH Ave. #1, Glendale, AZ 85304 (602) 978-6100 Fax: (602) 978-6555

Appointment and Cancellation Policy for Medical Appointments

Our goal is to provide quality medical care in a timely manner. In order to do so we have had to implement an

appointment/cancellation policy. The policy enables us to better utilize available appointments for our patients in need of medical

care.

Scheduled Appointments

For a scheduled appointment please call

602-978-6100 Ext 125

Cancellation of an Appointment

In order to be respectful of the medical needs of the community please be courteous and call our office promptly if you are unable to

attend an appointment. This time will be reallocated to someone who is in urgent need of treatment.

If it is necessary to cancel your scheduled appointment we require that you call 24 HOURS in advance. Appointments are in demand,

and your early cancellation will give another person the possibility to have access to timely medical care.

How to Cancel Your Appointment

To cancel appointments please call 602-978-6100 Ext. 118

Late Cancellations

Late cancellations will be considered as a “no show”.

No Show Policy

A “no show” is someone who misses an appointment without canceling it 24 HOURS in advance. No-shows inconvenience those

individuals who need access to medical care in a timely manner.

A failure to present at the time of a scheduled appointment will be recorded in the patients’ chart as a “no show”. An administrative

fee of $40.00 will be billed to the patient’s account. The patient will be sent a letter alerting them to the fact that they have failed to

show up for an appointment and did not cancel the appointment 24 HOURS in advance. A copy of the letter will be placed in the

patient file. Three “no shows” will result in the temporary suspension of services. In order to reinstate services the patient will be

required to meet with the practice administrator or delegate to evaluate the situation.

Life-threatening Emergencies

Always call 911 immediately in case of a life-threatening emergency.

SIGNED: DATE: __________-_________-__________

Patient/Legal Representative

Name of Patient:

AUTHORIZATION TO SPEAK WITH NEXT OF KIN

ARIZONA PREMIER PULMONARY & SLEEP SPECIALISTS 13606 N 59TH Ave Suite #1, Glendale, AZ 85304

Ph: (602) 978-6100 Fax: (602) 978-6555

MANJIT S. BHAMRAH, M.D., F.C.CP. SALAM RAFIQUE, M.D., F.C.C.P

PATIENT:____________________________________________________________ DOB:_______-_______-_______

For the purpose of continuity of care, I hereby authorize information about my medical condition (including treatment options, prescriptions, diagnostic tests, etc.) to be discussed with the following individual(s):

________________________________ _____________________________ ____________________________ Name Relationship to Patient Phone Number

_________________________________ _____________________________ ____________________________ Name Relationship to Patient Phone Number

I understand that this authorization may be changed or revoked at any time by giving written request to Paseo Medical Specialists, dba Arizona Premier Pulmonary & Sleep Specialists, and until such time, shall remain valid indefinitely. I also understand that I may request information to be discussed on a limited basis, such as:

(Describe any limitations that you do not wish to be disclosed with the individual(s) listed above):

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

Patient’s Signature:_________________________________________________ Date:_______-_______-_______

Witnessed by:____________________ ___________ _________________________

Staff Signature Date Staff Signature Date

Revised August 23rd, 2016

ARIZONA PREMIER PULMONARY & SLEEP SPECIALISTS

“Breathe Better, Sleep Better, Feel Better”

13606 N. 59th

Avenue #1, Glendale, AZ 85304

Today’s Date:

(This is a confidential record. Information contained here will not be released without your authorization)

Name (Last) (First) Age: Sex:

DOB: Primary Care Physician:

Main health reason for today’s visit:

How did you hear about us? ___Doctor ___Website/Internet ___Gym ___Friend/Family ___Drove by

Please describe your symptoms: (Leave blank what does not apply)

1. Cough:

How long have you had this cough? #___Days #___Weeks #___Months #___Years

What time of day/night is worse? ___Morning ___Daytime ___Mostly at night

How would you rate its severity? ___ Mild ___Moderate ___Severe

Has the cough ___Improved ___Worsened ___Stayed the same

Medication(s) tried?

Did medication give relief? ___Yes ___No

Do you repeatedly clear your throat due to post nasal drip? ___Yes ___No

Do you feel a lump in your throat? ___Yes ___No

Do you get heartburn or acid regurgitation? ___Yes ___No

Have you had any labs/blood drawn for this condition? ___Yes ___No

Have you had any chest X-ray or CT Chest performed? ___Yes ___No

Is there anyone in the family with a similar illness? ___Yes ___No

2. Sputum/Phlegm Production:

How much at a time? ___ ½ -1 Teaspoon ___½-1 Tablespoon What Color?

Is the amount - ___Increasing ___Decreasing ___Staying the same

3. Hemoptysis (Coughing up blood):

Was it fresh RED blood? ___Yes ___No

How much? ___Streaks ___Teaspoon ___Tablespoon

How often? #___Days #___Weeks #___Months #___Years

When was the last time this happened?

4. Dyspnea (breathing difficulty/shortness of breath):

How long have you felt short of breath? #___Days #___Weeks #___Months #___Years

How would you rate its severity? ___ Mild ___Moderate ___Severe ___Very Severe mMRC dyspnea scale (choose one of the following)(0 to 4 with 4=most severe)

___0 Dyspneic only on strenuous exercise

___1 Dyspneic on walking a slight hill or hurrying

___2 Dyspneic on walking level ground

___3 Must stop for breathlessness after walking just 100 yards

___4 Cannot leave house; breathless while dressing/undressing

Dyspnea continued…

How is it progressing? ___Improving ___Worsening ___Staying the same

What relieves your shortness of breath?

How many pillows do you use at night? ____ Is the head of your bed elevated? ___Yes ___No

5. Wheezing:

Have you noticed or has someone told you that you are wheezing? ___Yes ___No

When does the wheezing occur most? ___Day ___Night

6. Hoarseness:

Have you noticed any hoarseness? ___Yes ___No If Yes, when?

7. Chest pain:

Where is it located? ___Left ___Right ___Center ___Back Does the pain travel? ___Yes ___No

Description of pain? ___Sharp ___Dull ___Painful with breathing

How long does it last? #___Seconds #___Minutes #___Hours

What relieves it?

What worsens it?

Severity of pain on a scale of 1 to 10? (1=Mild, 10=Severe)

How long have you had this pain? #___Days #___Weeks #___Months #___Years

8. Asthma:

Have you ever had asthma? ___Yes ___No Do you still have it? ___Yes ___No

What age did asthma start? What age did asthma stop? ____

What symptom bothers you the most? ___Cough ___Wheezing ___Shortness of breath

ACT™

In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at

work, school or home? ___All of the time (1) ___Most of the time (2) ___Some of the time (3)

___A little of the time (4) ___None of the time (5)

During the past 4 weeks, how often have you had shortness of breath?

___More than once a day (1) ___Once a day (2) ___3 to 6 times a week (3)

___Once or twice a week (4) ___Not at all (5)

During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of

breath, chest tightness or pain) wake you up at night or earlier than usual in the morning?

___4 or more nights a week (1) ___2 or 3 nights a week (2) ___Once a week (3)

___Once or twice (4) ___Not at all (5)

During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such

as albuterol)? ___ 3 or more times per day (1) ___ 1 or 2 times per day (2)

___ 2 or 3 times per week (3) ___Once a week or less (4) ___ Not at all (5)

How would you rate your asthma control during the past 4 weeks? ___ Not controlled at all (1)

___Poorly controlled (2) ___ Somewhat controlled (3) ___ Well controlled (4)

___ Completely Controlled (5)

SCORE:______

9. How many ER visits have you had for your asthma? In the last 12 months ____

Have you been admitted to the hospital in the last 12 months for yo ur asthma? ___Yes ___No

When was the most recent exacerbation requiring ER visit?

Have you ever had a skin test for allergies? ___Yes ___No

Did you receive allergy shots? ___Yes ___No For how long?

10. Please mark with an “X” all that apply to you.

11. Past Pulmonary History (Please check all that apply)

X X

Asthma Pneumothorax (lung collapse)

Bronchitis (frequent) Pulmonary Embolism

Cystic Fibrosis Pulmonary Fibrosis

Chest Procedure (biopsy, surgery) Pulmonary Hypertension (In lungs)

Chest Trauma Respiratory Failure

COPD Restless Leg Syndrome

Deep Vein Thrombosis Rhinitis

Diaphragm Elevation/Paralysis Rib Fractures

Emphysema Sarcoidosis

Empyema (pus around the lung) Sickle Cell Disease/Trait

Hay Fever Sinusitis

Insomnia Sleep Apnea

Narcolepsy Tuberculosis exposure (when? )

Nasal Polyps Tuberculosis (positive PPD test)

Treatment? ___Yes ___No

Oxygen Dependence Tuberculosis in Lung

Pleural Effusion (fluid around lung) Whooping Cough

Pneumonia

X Constitutional: X Gastrointestinal: X Hematological: X Cardiovascular:

Recent Weight Loss Lbs:

Abdominal Pain Bleeding Tendency Chest Pain

Recent Weight Gain Lbs:

Difficulty Swallowing

Low Blood Count Ankle Swelling

Fever/Chills Nausea/Vomiting Anemia Palpitations

Night Sweats Heartburn/Acid in throat

X Eyes: X Musculoskeletal: X Endocrinal: X Psychiatric

Red Eyes Swollen Joints Excessive Thirst Depression

Dry Eyes Muscle Pain Heat/Cold Intolerance Anxiety

Blurred Vision Chronic Pain Kidney Dysfunction Panic Attacks

X Ears/Nose/Throat: X Dermatological: X Seasonal Allergies: X Neurological:

Sore Throat Skin Rash Pollen Fainting/Black Outs

Nasal Congestion Bruise Easily Grass Numbness in Toes/Fingers

Nose Bleeds Psoriasis Trees Frequent Headaches

Post Nasal Drip Stroke

Hoarseness

Feel Lump in Throat

12. Past Medical History

X X

Anxiety Year? Heart Murmur? Year?

Arthritis Year? Hepatitis? Year?

Atrial Fibrilation Year? High Blood Pressure Year?

Cancer, Which Organ______ Year? High Cholesterol Year?

Chronic Kidney Disease Year? Liver Cirrhosis Year?

Colitis Year? Lupus Year?

Congestive Heart Failure Year? Neuromuscular Disease Year?

Coronary Artery Disease Year? Polio Year?

Crohn’s Disease Year? Rheumatic Fever Year?

Depression Year? Stomach Ulcers Year?

Diabetes Year? Stroke/Brain attack Year?

GERD Year? Thyroid Problem Year?

Heart Attack/Angina Year? Other:

13. Past Surgical History

List all surgeries, operations, and procedures that you have had YEAR

1.

2.

3.

4.

5.

6.

Have you ever had a bronchoscopy? ___Yes ___No When? Where?

Have you ever had nasal/sinus surgery? ___Yes ___No When? Where?

14. Personal and Social History

How long have you been in Arizona? Born/Raised where?

Marital Status: ___Married ___Single ___Widowed ___Divorced

Any mold problems in your home? ___Yes ___No Do you have a swamp cooler? ___Yes ___No

Current occupation:_______________________________________________________________

Have you ever worked in/as: __Miner __Sandblaster __Granite worker __Welder __Shipyard

__Pipe fitter __Electrician __Farm worker __Aerospace __Nuclear __Electronic industry

Have you ever been exposed to ___Asbestos ___Silica Dust

Tobacco: No Cigarettes Cigars E-cigarettes Chewing Tobacco

Age began?___ Quit? ___ Yes ___ No Age Quit?___ Years Smoked?___ # of packs per day?____

What products have you used to try and quit? ___Gum ___Patches ___Chantix ___Other

Alcohol:

Do you drink Alcohol? ___Yes ___No How often? ___Rarely ___Socially ___Daily ___Weekly

If no, did you quit? ___Yes ___No At what age did you begin drinking? ______ Age quit?

Street Drugs:

Have you ever used any “Street Drugs”? ___Yes ___No What kind? How long?

15. Immunizations:

Pneumovax: ___Yes ___No When was last pneumonia vaccine?

Influenza: ___Yes ___No When was last influenza vaccine?

16. Pets:

Do you have any pets? ___Yes ___No ___Indoor ___Outdoor

What kind? ___Cats ___Dogs ___Birds ___Other

17. Travel History:

Any recent travel?

Have you ever lived outside of the U.S.? ___Yes ___No Where/How long?

18. Daily Activities:

List activities of a typical day, include hobbies:

19. Family History:

Mother Father Siblings

Asthma/Eczema/Hay Fever

Blood Clots in Legs

Cystic Fibrosis

Emphysema/COPD

Cancer Organ?_______________________

Tuberculosis

Diabetes

Heart Disease

Cause of death (if known)

Above history completed by Patient or Other (Other’s Name/Relation:

Patient Signature:

Patient Name: DOB: Today’s Date:______________

MEDICATION NAME DOSE HOW OFTEN START DATE

REASON FOR TAKING

DRUG ALLERGIES

NKDA (NO KNOWN DRUG ALLERGIES)

DRUG REACTION

Reactions include anaphylaxis, rash, hives, difficulty breathing, itching, nausea, vomiting, etc

Pharmacy: Name:__________________

Cross Streets:____________________ (Please put down pharmacy information!!)

ARIZONA PREMIER PULMONARY & SLEEP SPECIALISTS

SLEEP HISTORY FORM PATIENT NAME:

DOB: _________________ TODAY'S DATE: _________

1. Do you SNORE? ......................................................................... □ Yes □ No

2. Rate your snoring? □MILD □MODERATE □LOUD □VERY LOUD

3. How long has this been occurring? □ Weeks □ Months □ Years

4. Have you been told you hold your breath or Stop breathing in your sleep? ..... □ Yes □ No

5. Do you awaken suddenly with a choking sensation or feeling out of breath? ... □ Yes □ No

6. When you awaken in the morning, do you feel refreshed?............................ □ Yes □ No

7. Do you awaken with headaches in the morning? ........................................ □ Yes □ No

8. Do you feel sleepy/fatigued during the day?.............................................. □ Yes □ No

9. Do you have to fight sleep while driving? ................................................. □ Yes □ No

10. Have you ever had a sleep study? ........................................................... □ Yes □ No When? Where?

PLEASE RATE THE CHANCE OF YOU DOZING IN THE FOLLOWING SITUATIONS:

0-WOULD NEVER DOZE 1=SLIGHT CHANCE 2=MODERATE 3=HIGH CHANCE

1 . Sitting and reading 0 1 2 3

2 . Watching TV 0 1 2 3

3 . Sitting inactive in a public place (ex: theater or meeting) 0 1 2 3

4 . As a passenger in a car for an hour without at break 0 1 2 3

5 .

Lying down to rest in the afternoon, if circumstances permit 0 1 2 3

6 . Sitting and talking to someone 0 1 2 3

7 . Sitting quietly after a lunch (without alcohol) 0 1 2 3

8 . In a car, while stopped for a few minutes in traffic 0 1 2 3

Have you gained weight in the last few years? □Yes □No How many pounds? _________

Normal Bedtime on Weeknights: ______ Weekends: ________

Normal Wake up on Weekdays: _______ Weekends: ________

How long does it usually take for you to fall asleep, once the lights are turned off? ______

Do you awaken during the night? □Yes □No How many times? ____________________

Do you awaken at night to urinate? □Yes □No How many times? ____________________

How long does it take you to return to sleep after these awakenings? _________________

Do you have restless legs/kicking/thrashing in your sleep? □Yes □No

Do you grind your teeth at night? □Yes □No

Do you take naps during the day? □Yes □No How often? ______ Length of nap? _______

Do you feel refreshed upon awakening from these naps? □Yes □No

When you awaken from sleep, do you feel paralyzed, unable to move, even though you are awake? □Yes □No

When startled or laughing, do you get weak, fall or do your knees buckle? □Yes □No

While in the process of falling asleep, do you have vivid dreams or hallucinations? □Yes □No

Do you have frequent uncontrollable bouts of sleep or an irresistible urge to sleep? □Yes □No

Circle if at least one of the following forms of daytime impairment is related to the nighttime sleep difficulty:

1. Fatigue or malaise

2. Attention, concentration, or memory impairment

3. Social or vocational dysfunction or poor school performance

4. Mood disturbance or irritability

5. Daytime sleepiness

6. Motivation, energy, or initiative reduction

7. Proneness for errors or accidents at work or while driving

8. Tension, headaches, or gastrointestinal symptoms in response to sleep loss

9. Concerns or worries about sleep

ARIZONA PREMIER PULMONARY & SLEEP SPECIALISTS

13606 N 59TH AVE. #1, GLENDALE, AZ 85304

INSOMNIA QUESTIONNAIRE

□ Not applicable

Patient Name: DOB:

1. How long have you had the inability to fall asleep or remain asleep for an adequate length of

time?

_____Days _____ Weeks _____ Months _____ Years

2. What do you do prior to bedtime at night?

3. What time do you get into bed at night?

4. Do you watch TV or read at that time?

5. Do you fall asleep with the TV on?

a. If so, when do you turn it off?

6. How long does it take you to fall asleep when you turn out the lights?

7. Do you sleep through the night or do you awaken frequently?

8. How often do you awaken?

9. How long does it take you to return to sleep?

10.What do you do when awake at night?

11.Do you ever become angry or upset when awake in the middle of the night?

12.Do you look at the clock when you awaken during the night?

13.Do you ever have something to eat during the night?

14.What time do you get out of bed in the morning to start your day?

15.How long have you had this sleep pattern?

16.How much total sleep do you get per night?

17.How much sleep do you need to feel rested during the day?

18.How does your sleep-wake schedule change on weekends (or days off)?

19.What time did you go to bed and arise before you began to sleep poorly?

20.What treatments have you tried for sleep?

21.If medication was used, what was the dosage?

22.What time did you take it and how long did you take it?

23.Did you take it every night? If no, how did you decide which nights you would take it?

24.Did you ever take additional medication beyond what was prescribed?

25.Did you ever take additional medication in the middle of the night after awakening?

26.How effective was the medication at improving sleep onset and sleep maintenance?

27.Was there any evidence of side effects such as daytime sedation, motor impairment, or

memory impairment?

28.Was daytime function improved in any way with the use of medication?

29.Are you taking medication currently?

Automated visit reminder system

Dear _________________________________: Print Name

Recently, our office implemented an automated visit reminder

calling system. As part of this system, we will be able to send you a

text message reminding you of your scheduled appointment and also

remind you to make future appointments with our office.

If you are interested in receiving text messages instead of

reminder phone calls, please check the box below and sign and date.

Opting to receive text message reminders will automatically

remove your name from receiving phone call reminders.

□ Yes, please text me reminder at ______-______-________

(Must be a cell phone number)

Signature:__________________________ Date:__________

□ I prefer receiving automated reminder phone calls.

Thank you so much for your time.

Sincerely,

Amy D. Saenz

Office Manager

MANJIT BHAMRAH, M.D., F.C.C.P.

Diplomate of American Board of

Pulmonary Medicine & Sleep Medicine

SALAM RAFIQUE, M.D., F.C.C.P.

Diplomate of American Board of

Pulmonary Medicine & Sleep Medicine

Consultation

Pulmonary Disease

Asthma Clinic

COPD Clinic

Lung Mass Clinic

Lung Nodule Clinic

Valley Fever Clinic

Bronchoscopy & Biopsy

Sleep Apnea Clinic

Insomnia Clinic

Polysomnogram Interpretation

State of the art Lab

Pulmonary Function Testing

Cardiopulmonary Exercise Testing

Proud Member of VFAAC

Valley Fever Alliance of Arizona Clinicians

13606 North 59th Avenue Suite #1

Glendale, Arizona 85304

Tel: 602-978-6100

Fax: 602-978-6555

www.azpremierpass.com

MANJIT BHAMRAH, M.D., F.C.C.P.

Diplomate of American Board of

Pulmonary Medicine & Sleep Medicine

SALAM RAFIQUE, M.D., F.C.C.P.

Diplomate of American Board of

Pulmonary Medicine & Sleep Medicine

Consultation

Pulmonary Disease

Asthma Clinic

COPD Clinic

Lung Mass Clinic

Lung Nodule Clinic

Valley Fever Clinic

Bronchoscopy & Biopsy

Sleep Apnea Clinic

Insomnia Clinic

Polysomnogram Interpretation

State of the art Lab

Pulmonary Function Testing

Cardiopulmonary Exercise Testing

Proud Member of VFAAC

Valley Fever Alliance of Arizona Clinicians

13606 North 59th Avenue Suite #1

Glendale, Arizona 85304

Tel: 602-978-6100

Fax: 602-978-6555

www.azpremierpass.com

PATIENT RESPONSIBILITIES

As a patient at Arizona Premier Pulmonary & Sleep Specialists, you have certain reponsibilies

in order to ensure that your healthcare is the best that it can be. They are as follows:

1. Ensure that this office accepts your insurance.

a. Please refer to your insurance plans website or booklet for a listing of all allowed

providers. If we are out of network, you may receive a bill from our office and it is

your responsibility to cover the non-covered costs associated with your care.

b. Not all exams and/or procedures are covered at 100%. It is your responsibility to

find out what your out of pocket costs will be prior to having the exam and/or

procedure. This includes, unmet deductibles, co-pays and co-insurance costs.

2. Follow all instructions given by your physican directly or via the office staff.

3. Get all procedures, labs or exams that are ordered and recommended by your

physician. If the procedure is to take place in our office, (i.e. Sleep studies, CPFTs and

CPX) it is your responsibility to call and set that appointment date and time.

4. Schedule and keep follow up appointments as recommended by your physician.

a. Reminder phone calls are a courtesy. If you do not receive a reminder call, it is

still your responsibility to keep your appointments.

5. If you are not able to make the appointment, you must call 24-hours in advance to notify

the office. A $40.00 late cancellation/no show fee may apply if you do not give proper

notice.

6. Reschedule any follow up that was cancelled or that you were unable to attend.

7. If you have an emergency after hours and are not able to reach the provider on call, it is

your responsibility to seek out alternative emergency care. (i.e. Call 911 or go to closest

emergency room)

Additionally, please direct all financial issues to the office manager.

I acknowledge that I have read and understand my responsibilities as a patient of Dr. Manjit Bhamrah and

Dr. Salam Rafique.

Patient Signature: Date: