Patient & Physician Forms
Print these forms. Fill them out completely then bring them with you at your first visit.
In order to view these forms you must have Adobe Acrobat Reader installed on your computer.

Patient Forms Authorization to Use or Disclose Health Information File: Authorization to Disclose Health Form.pdf Type: Adobe Acrobat PDF Patient Information Form File: Patient Information Form.pdf Type: Adobe Acrobat PDF Sleep Questionnaire and Sleep Log File: Sleep Questionnaire and Sleep Log.pdf Type: Adobe Acrobat PDF

Dear Patient, We want to take this opportunity to welcome you to our sleep center and thank you for choosing us to provide your health care. We appreciate your trust in us and look forward to keeping you healthy. Please complete the enclosed information BEFORE your scheduled appointment and bring the completed forms (Health Disclosure Form, Patient Information Form, Patient Questionnaire, Sleep Log) with the requested information including current insurance card(s), all your medications (including inhalers, over-the-counter medications, herbs) and your CPAP or BiPAP machine if you are using one. The Sleep and Health questionnaires are helpful to conduct this sleep study/office consultation so it is very important that this is completely filled out ahead of time. **Please note we have also included a 7 day sleep log that must be completed by you prior to coming in for your scheduled appointment. If a referral is required, you will need to bring your referral and/or referral information to the office at the time of your visit. If you have any questions concerning your benefits, please call your insurance company. If you need to reschedule your appointment, please call us at (810) 225-7595 as early as possible, but no later than 24 hours prior, or you will be subject to a late cancellation/ missed appointment fee of $150.00 per sleep study or $25 per office consultation. Sincerely, Staff at Mid-West Center for Sleep Disorders