Diagnostic & Treatment Center for Sleep Disorders

19441 Golf Vista Plaza, Suite 230, Lansdowne, VA 20176 • 14141 Robert Paris Court, Chantilly, VA 20151 • 200 N. Glebe Road, Suite 316, Arlington, VA 22203

4897 Prince William Parkway, Suite 102, Woodbridge, VA 22192 • 3687 Fettler Park Drive, Dumfries, VA 22025

12321 Middlebrook Road, Germantown, MD 20874 • 8100 Ashton Ave., Suite 216 Manassas, VA 20109•

6000 Executive Blvd, Suite 604, North Bethesda, MD 20852

Phone: 703 -729-3420 Fax: 703-729-3422 • www.ComprehensiveSleepCare.com

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PATIENT INFORMATION

Patient Full Name: ________________________________ Prefix/Suffix: __________________ Todays Date: _____/_____/_____

Sex:  M /  F Date of Birth: _____/_____/_____ Age: _________ Social Security #: ________-________-_________

Home Address: ______________________________City: ____________________State: __________Zip: ____________

Home Phone #: ________-________-_________ Mobile Phone #: ________-________-_________

Email Address: ______________________________________ Marital Status:  Single  Married  Divorced  Widow

Language:  English  Spanish  Indian (Hindi/Tamil)  Russian  Other _______________________________________

Ethnicity:  Caucasian  American  Indian  Asian  African American  Hispanic

 Native Hawaiian or  Pacific Islander  Other ______________________________________

EMPLOYER | PHARMACY INFORMATION

Employer: __________________________________________ Employer Phone #: ________-________-_________

Job Status:  FULL TIME  PART TIME  STUDENT  RETIRED

Employer Address: ______________________________________ City: ____________________State: __________Zip: ____________

Preferred Pharmacy: __________________________________ Pharmacy Phone #: ________-________-_________

Pharmacy Address: ________________________________ City: ____________________State: __________Zip: ____________

CONTACT / GUARANTOR INFORMATION

NEXT OF KIN CONTACT (please check at least one)  Emergency Contact  Next of Kin  Authorized to Seek Treatment

Last Name: _______________________ First Name: _______________________ Middle Initial: _____________________

Social Security #: ________-________-_________ Relationship to Patient: _______________________ Sex:  M /  F

Date of Birth: _____/_____/_____ Home Address: ___________________________________________________________

Employer: _______________________ Work Phone #: ________-________-_________ Job Title: _____________________

NEXT OF KIN CONTACT (please check at least one)  Emergency Contact  Next of Kin  Authorized to Seek Treatment

Last Name: _______________________ First Name: _______________________ Middle Initial: _____________________

Social Security #: ________-________-_________ Relationship to Patient: _______________________ Sex:  M /  F

Date of Birth: _____/_____/_____ Home Address: ___________________________________________________________

Employer: _______________________ Work Phone #: ________-________-_________ Job Title: _____________________

If the Guarantor information is left blank, the patient will be assumed to be the responsible/billed party.

GUARANTOR CONTACT (please check at least one)  Guarantor  Policy Holder/Insured

Last Name: _______________________ First Name: _______________________ Middle Initial: _____________________

Social Security #: ________-________-_________ Relationship to Patient: ______________________ Sex:  M /  F

Date of Birth: _____/_____/_____ Home Address: ___________________________________________________________

Employer: _______________________ Work Phone #: ________-________-_________ Job Title: _____________________

Diagnostic & Treatment Center for Sleep Disorders

19441 Golf Vista Plaza, Suite 230, Lansdowne, VA 20176 • 14141 Robert Paris Court, Chantilly, VA 20151 • 200 N. Glebe Road, Suite 316, Arlington, VA 22203

4897 Prince William Parkway, Suite 102, Woodbridge, VA 22192 • 3687 Fettler Park Drive, Dumfries, VA 22025

12321 Middlebrook Road, Germantown, MD 20874 • 8100 Ashton Ave., Suite 216 Manassas, VA 20109•

6000 Executive Blvd, Suite 604, North Bethesda, MD 20852

Phone: 703 -729-3420 Fax: 703-729-3422 • www.ComprehensiveSleepCare.com

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PHYSICIAN INFORMATION: IMPORTANT PLEASE PROVIDE BOTH PHYSICANS

How did you find us?  Referring or Primary Care Physician  Internet  Advertisement  Insurance Company

 Family/Friend : _____________________________________________________________________________________

Referring Physician Name: ________________________

Address: ______________________________________

City: _____________ State: _____ Zip: ______________

Phone #: ________-________-_________

Fax #: ________-________-_________

Primary Care Physician: __________________________

Address: ______________________________________

City: _____________ State: _____ Zip: ______________

Phone #: ________-________-_________

Fax #: ________-________-_________

INSURANCE POLICY INFORMATION

Type (please check one only)  Health  Auto  Workers Comp  Other: _________________________________________

PRIMARY INSURANCE NAME: __________________________________________________________________________

Claims Address: ______________________________________________________ Phone #: ________-________-_________

Policy #: _________________________________________ Group #: ____________________________________________

Policy Holder Information (if different)

Policy Holder Name: _____________________________________ Policy Holder DOB: _____/_____/_____

Policy Holder Phone #: ________-________-_________ Policy Holder SS #: ________-________-_________

SECONDARY INSURANCE NAME

Type (please check one only)  Health  Auto  Workers Comp  Other: _________________________________________

SECONDARY INSURANCE NAME: ______________________________________________________________________

Claims Address: ______________________________________________________ Phone #: ________-________-_________

Policy #: _________________________________________ Group #: ____________________________________________

Policy Holder Information (if different)

Policy Holder Name: _____________________________________ Policy Holder DOB: _____/_____/_____

Policy Holder Phone #: ________-________-_________ Policy Holder SS #: ________-________-_________

TERTIARY INSURANCE NAME (IF APPLICABLE)

Type (please check one only)  Health  Auto  Workers Comp  Other: _________________________________________

TERTIARY INSURANCE NAME: ______________________________________________________________________

Claims Address: __________________________________________________________ Phone #: ________-________-_________

Policy #: _________________________________________ Group #: ____________________________________________

Policy Holder Information (if different)

Policy Holder Name: _____________________________________ Policy Holder DOB: _____/_____/_____

Diagnostic & Treatment Center for Sleep Disorders

19441 Golf Vista Plaza, Suite 230, Lansdowne, VA 20176 • 14141 Robert Paris Court, Chantilly, VA 20151 • 200 N. Glebe Road, Suite 316, Arlington, VA 22203

4897 Prince William Parkway, Suite 102, Woodbridge, VA 22192 • 3687 Fettler Park Drive, Dumfries, VA 22025

12321 Middlebrook Road, Germantown, MD 20874 • 8100 Ashton Ave., Suite 216 Manassas, VA 20109•

6000 Executive Blvd, Suite 604, North Bethesda, MD 20852

Phone: 703 -729-3420 Fax: 703-729-3422 • www.ComprehensiveSleepCare.com

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Policy Holder Phone #: ________-________-_________ Policy Holder SS #: ________-________-_________

FINANCIAL POLICY

This consent applies to Loudoun Medical Group, PC (herein after referred LMG) d/b/a Comprehensive Sleep Care Center, or any of its

affiliates or agents, lenders, or any third party servicer acting for LMG or any of its affiliates.

I hereby authorize my insurance benefits to be paid directly to the physician and/or physician group for which I am financially responsible for

all charges. I also consent to the release and re-disclosure of my medical record to enable or facilitate the payment, collection, verification or

settlement of my account for any amounts due from me or any third party payor, health maintenance organization, insurer or other health

benefit plan.

Our office will provide you a general breakdown of coverage on your first visit and this information will be disclosed to you via a “Call In

Form” which you are required to sign. Please note, this information is used for obtaining preliminary insurance information only and this is

not a guarantee of benefits; we highly recommend that you contact your insurance carrier to get more specific approval for all services.

**If the “Call in Form” was not reviewed with you at your Initial appointment, please notify the front desk immediately so that this

can be provided for you.

If at any point you change insurance, or your insurance policy terminates or cancels coverage, you will be fully responsible for any and all

charges that are not subject to being refiled with any new insurance provided. Most insurance(s) have timely filing requirements that if they

are not met we are not able to rebill those services. It is imperative that you notify our office immediately of any changes to your policy.

**If we are unable to refile your claims you will be fully responsible for all charges. This includes any SECONDARY insurance related

information as well.

REFERRAL POLICY

I understand that if my insurance carrier requires a written “Insurance Referral” from my Primary Care Physician, I am responsible for

obtaining the insurance referral prior to being seen in our office and prior to be testing.

We recommend that all patients call and confirm this directly with your health insurance or check with your PCP office ahead of time. If an

“insurance referral” has not been obtained before my appointment, I will be asked to sign a “Waiver Form” acknowledging that if the referral

is not able to be obtained timely I will be financially responsible for the charges incurred.

CANCELLATION POLICY

We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However,

when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment. Conversely,

the situation may arise where another patient fails to cancel and we are unable to schedule you for a visit, due to a seemingly “full”

appointment book.

*Office Visit appointment not cancelled within (48) business hours will be charged $30.00 cancellation fee-this fee is NOT billable to your

insurance carrier.

*Sleep Study related appointments not cancelled within (72) business hours will be charged $150.00 cancellations fee-this fee is NOT

billable to your insurance carrier. For all Sleep Study related appointments, we have arranged in advance to have a Registered

Polysomnogram Sleep Technician available to provide your Sleep Study.

* If you must cancel or reschedule your appointment, we ask that you contact us directly at 703.729.3420, OPTION# 3

(Monday-Friday 8:00am-4:00pm).

Print Name: _______________________ Date: _____/_____/_____ Signature: ___________________________________

Diagnostic & Treatment Center for Sleep Disorders

19441 Golf Vista Plaza, Suite 230, Lansdowne, VA 20176 • 14141 Robert Paris Court, Chantilly, VA 20151 • 200 N. Glebe Road, Suite 316, Arlington, VA 22203

4897 Prince William Parkway, Suite 102, Woodbridge, VA 22192 • 3687 Fettler Park Drive, Dumfries, VA 22025

12321 Middlebrook Road, Germantown, MD 20874 • 8100 Ashton Ave., Suite 216 Manassas, VA 20109•

6000 Executive Blvd, Suite 604, North Bethesda, MD 20852

Phone: 703 -729-3420 Fax: 703-729-3422 • www.ComprehensiveSleepCare.com

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MEDICAL RECORDS POLICY

MEDICAL RECORDS POLICY: NO CHARGE FOR THE FIRST (10) PAGES, THEN $0.50 PER PAGE UP TO (50) PAGES AND $0.25 A

PAGE THEREAFTER FOR COPIES FROM PAPER, PLUS A $10.00 RETRIEVAL/PROCESSING FEE. ALL POSTAGE AND SHIPPING

COSTS ARE INCLUDED.

VA Code: 32.1-127.1:03 Health care records must be made available electronically only as authorized by the HITECH Act and HIPAA.

A health care entity does not need to provide records in a requested electronic format if: Such format is not reasonably available without

additional cost to the entity. If the records would be subject to modification in the format requested; or if the entity determines that the

integrity of the records could be compromised in the format requested.

**PLEASE NOTE, our office is unable to provide records returned via the email system due to the HITECH ACT. It is our office

policy that you are only able to pick them up and/or have them mailed to the address on file. The fee for the records must be paid

in advance before records will be provided.

Any and all requests for access to health records must be made in writing via mail to:

19441 Golf Vista Plaza, Suite 230, Attention: Medical Records, Lansdowne, VA 20176 or to the email assigned –

[email protected].

The request must be dated, signed by the requestor; you must also provide your full name, date of birth, last 4 of Social Security Number

and provide your mailing address (This must match what we have on file for you). There is a form available for you to complete and can and

will be provided upon request to notify us as to the nature of the information requested, include evidence of the requestor’s authority to

receive access, identify the person to whom information is to be disclosed, and specify the preferred format.

Within (15) days of receiving a request for access, the entity must take one of the following actions: Furnish the copies of or allow access to

the requested records in electronic format, if requested; If the information does not exist or cannot be found, inform the requestor; If the

entity does not maintain a record of the information, inform the requestor and provide the name and address of the entity that does maintain

the record, if known; or deny the request.

CONSENT FOR SPOUSES OR PERSON WE CAN SHARE YOUR HEALTH PROTECTED INFORMATION WITH:

We understand the importance of being able to communicate or share certain pieces of health related information to your family members or

spouses. The HIPPA Privacy Act requires that must obtain permission from you before we can share any health related information which

includes: Appointments, Insurance/Account billing, and treatment related information as well. If you would like for us to be able to share

certain pieces of this information, please make sure you list their names below and designate their relationship to you and check the boxes

applicable. YOU MAY OPT OUT OF THIS CONSENT BY PROVIDING WRITTEN NOTIFICATION.

1. ___________________________________ (first and last name required) _____/_____/_____ (DOB-required)

Relationship  spouse  family member ______________ guardian  Payment/Ins Info  Medical Info  Appointments

2. ___________________________________ (first and last name required) _____/_____/_____ (DOB-required)

Relationship  spouse  family member _______________ guardian  Payment/Ins Info  Medical Info  Appointments

3. ___________________________________ (first and last name required) _____/_____/_____ (DOB-required)

Relationship  spouse  family member _______________ guardian  Payment/Ins Info  Medical Info  Appointments

Diagnostic & Treatment Center for Sleep Disorders

19441 Golf Vista Plaza, Suite 230, Lansdowne, VA 20176 • 14141 Robert Paris Court, Chantilly, VA 20151 • 200 N. Glebe Road, Suite 316, Arlington, VA 22203

4897 Prince William Parkway, Suite 102, Woodbridge, VA 22192 • 3687 Fettler Park Drive, Dumfries, VA 22025

12321 Middlebrook Road, Germantown, MD 20874 • 8100 Ashton Ave., Suite 216 Manassas, VA 20109•

6000 Executive Blvd, Suite 604, North Bethesda, MD 20852

Phone: 703 -729-3420 Fax: 703-729-3422 • www.ComprehensiveSleepCare.com

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

 I DO NOT WANT MY INFORMATION SHARED WITH ANYONE

CONSENT FOR VIDEO TAPINGS

As part of a diagnostic sleep study, video surveillance may be required. All information and data will be kept confidential.

I, ______________________________,hereby authorize the use of video surveillance for the purpose of medical diagnosis. If the patient

being tested is a minor (under 18 years of age), he/she must be accompanied by a guardian for the entire test.

Patient / Guardian Signature: _____________________________________________________Date: _____/_____/_____

VOICEMAIL | EMAIL | SMS TEXT OPT-IN AGREEMENT

Our office understands that you may be very busy when it comes to being reminded about appointment(s) with your providers, our office has

a system in place so that we can notify you of any appointment that is scheduled and you can receive these reminders via TEXT or

VOICEMAIL. **Please indicate below if you would like to Opt-In or Out for these service(s).

Please note- that you are able to Opt Out anytime for all automated calls / texts, you will still receive Live calls reminding you of the

appointments unless you indicate DO NOT CALL.

A. VOICE MAIL OPTIONS: An automated call is made to your either your home, office or cell phone in which you can designate the

location to be called and the preferred language chosen can be (English/Spanish), you can also designate when you would like to

have these calls sent to you for either (morning/afternoon/evening). Please read and check all applicable. YOU ARE STILL

REQUIRED TO FOLLOW THE CANCELLATION POLICY. Voice and Text Options have to be the same for the Language/Time

Set; must be one or the other cannot be different.



 Opt-In Voice Call to:  Home  Office  Cell (please follow the prompts provided to confirm these appointments)

 English  Spanish  Morning  Afternoon  Evening  I DO NOT WANT TO RECEIVE AUTOMATED VOICE REMINDERS.

B. SMS TEXT OPTIONS: A text is made to your cell phone provided, you can designate the preferred language (English/Spanish),

you can also designate the time your texts are sent to you. Additional rates may apply from your carrier for this feature.

 Opt-In  Cell Text (please follow the prompts provided to confirm these appointments)  English  Spanish  Morning

 Afternoon  Evening  I DO NOT WANT TO RECEIVE AUTOMATED TEXT REMINDERS.

C. EMAIL NOTIFICATIONS: Our office will need to reach out to you via email from time to time if we have not been able to reach you

to confirm an appointment or if we need to provide you any inner office communication for your medical purposes only. We do not

use your email for solicitation services and you can Opt-Out of any notices being provided to you as well.

 Opt-In  I DO NOT WANT TO RECEIVE EMAIL NOTIFICATIONS

Patient / Guardian Signature: _____________________________________________________Date: _____/_____/_____

Diagnostic & Treatment Center for Sleep Disorders

19441 Golf Vista Plaza, Suite 230, Lansdowne, VA 20176 • 14141 Robert Paris Court, Chantilly, VA 20151 • 200 N. Glebe Road, Suite 316, Arlington, VA 22203

4897 Prince William Parkway, Suite 102, Woodbridge, VA 22192 • 3687 Fettler Park Drive, Dumfries, VA 22025

12321 Middlebrook Road, Germantown, MD 20874 • 8100 Ashton Ave., Suite 216 Manassas, VA 20109•

6000 Executive Blvd, Suite 604, North Bethesda, MD 20852

Phone: 703 -729-3420 Fax: 703-729-3422 • www.ComprehensiveSleepCare.com

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NOTICE OF DEEMED CONSENT FOR HIV, HEPATITIS B OR C TESTING

LMG is required by § 32.1-45.1 of the Code of Virginia (1950), as amended, to give you the following notice:

1. If any LMG health care professional, worker or employee should be directly exposed to your blood or body fluids in a way that may

transmit disease, your blood will be tested for infection with human immunodeficiency virus (the “AIDS” virus), as well as for

Hepatitis B and C. A physician or other health care provider will tell you the result of the test. Under VA Code § 32.1-45.1(A), you

are deemed to have consented to the release of the test results to the person exposed.

2. If you should be directly exposed to blood or body fluids of a LMG health care professional, worker or employee in a way that may

transmit disease, that person’s blood will be tested for infection with human immunodeficiency virus (the “AIDS” virus), as well as

for Hepatitis B and C. A physician or other health care provider will tell you and that person the result of the test.

I understand that this consent will remain in effect as long as my dependent or I receive care from LMG or until I withdraw it.

Print Name: _______________________ Date: _____/_____/_____ Signature: ___________________________________

GENERAL MEDICAL RECORDS RELEASE AND AUTHORIZATION FOR USE

OR DISCLOSURE OF PROTECTED HEALTH INFORMATION

Please complete the following information:

Patient Name: ________________________________________Date of Birth: _____/_____/_____SSN: __________ (last 4 only)

Address: ____________________________________City: ______________________State: _____________ Zip:____________

Phone Home: ________-________-_________Phone Cell: ________-________-_________

I authorize the custodian of records, or other person/entity (specifically describe) to disclose/release

the following information:* (check all applicable)

 All Records  Billing Records  Sleep Study Data / Report / Video  Progress Notes  Pharmacy / Prescription Records

 Other (describe specifically): _________________________________________________________________

*Note: If these records contain any information from previous providers or information about HIV/AIDS status, cancer diagnosis,

drug/alcohol abuse, or sexually transmitted disease, you are hereby authorizing disclosure of this information.

These records are for services provided on the following date(s): _____/_____/_____ thru _____/_____/_____

Diagnostic & Treatment Center for Sleep Disorders

19441 Golf Vista Plaza, Suite 230, Lansdowne, VA 20176 • 14141 Robert Paris Court, Chantilly, VA 20151 • 200 N. Glebe Road, Suite 316, Arlington, VA 22203

4897 Prince William Parkway, Suite 102, Woodbridge, VA 22192 • 3687 Fettler Park Drive, Dumfries, VA 22025

12321 Middlebrook Road, Germantown, MD 20874 • 8100 Ashton Ave., Suite 216 Manassas, VA 20109•

6000 Executive Blvd, Suite 604, North Bethesda, MD 20852

Phone: 703 -729-3420 Fax: 703-729-3422 • www.ComprehensiveSleepCare.com

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GENERAL MEDICAL RECORDS RELEASE AND AUTHORIZATION FOR USE

OR DISCLOSURE OF PROTECTED HEALTH INFORMATION-“CONTINUED”

Please send the records listed above to: (use additional sheets if necessary)

Name: ___________________________________

Address: ________________________________

City: __________________State: _____Zip: __________

Phone: (______) ________- __________

Fax: (______) ________- __________

Name: ___________________________________

Address: _______________________________

City: __________________State: _____Zip: __________

Phone: (______) ________- __________

Fax: (______) ________- __________

This authorization shall expire not later than: _____/_____/_____ or (whichever is sooner), and may not be valid for greater than one year

from the date of signature for Virginia medical records.

I understand that after the custodian of records discloses my health information, it may no longer be protected by federal privacy laws.

I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my

ability to obtain treatment, receive payment, or eligibility for benefits unless allowed by law but it may permit me from being able to retrieve

records on my behalf from other providers.

By signing below I represent and warrant that I have authority to sign this document and authorize the use or disclosure of protected health

information and that there are no claims or orders pending or in effect that would prohibit, limit, or otherwise restrict my ability to authorize

the use or disclosure of this protected health information.

____________________________________________ ____________________________________________

Signature of Patient: (or Patient’s Personal Representative) Printed Name of Patient Representative:

______________________________________________ _______/_______/_______

Representative’s for patient: (i.e. – parent, guardian) Date

Diagnostic & Treatment Center for Sleep Disorders

19441 Golf Vista Plaza, Suite 230, Lansdowne, VA 20176 • 14141 Robert Paris Court, Chantilly, VA 20151 • 200 N. Glebe Road, Suite 316, Arlington, VA 22203

4897 Prince William Parkway, Suite 102, Woodbridge, VA 22192 • 3687 Fettler Park Drive, Dumfries, VA 22025

12321 Middlebrook Road, Germantown, MD 20874 • 8100 Ashton Ave., Suite 216 Manassas, VA 20109•

6000 Executive Blvd, Suite 604, North Bethesda, MD 20852

Phone: 703 -729-3420 Fax: 703-729-3422 • www.ComprehensiveSleepCare.com

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LOUDOUN MEDICAL GROUP

Receipt of Notice of HIPAA Privacy Practices Acknowledgement

______________________________

Patient’s Name

I have a received a copy of Loudoun Medical Group’s Notice of Privacy Practices and understand

that the notice describes how my/the patient’s medical information may be used and how access

to this information may be obtained. I have also been given an opportunity to ask questions

about the information provided in the Notice.

Signature

Date:

Relationship to Patient (if Acknowledgement Form is

executed by someone other than the Patient)

FOR OFFICE USE ONLY

I attempted to obtain the patient’s/representative’s signature in acknowledgement

of this Receipt of Notice of Privacy Practices Acknowledgement, but was unable to

do so as documented below:

Date

Staff Initials

Reason

Refused to sign (circle if applicable)

Other:

Diagnostic & Treatment Center for Sleep Disorders

19441 Golf Vista Plaza, Suite 230, Lansdowne, VA 20176 • 14141 Robert Paris Court, Chantilly, VA 20151 • 200 N. Glebe Road, Suite 316, Arlington, VA 22203

4897 Prince William Parkway, Suite 102, Woodbridge, VA 22192 • 3687 Fettler Park Drive, Dumfries, VA 22025

12321 Middlebrook Road, Germantown, MD 20874 • 8100 Ashton Ave., Suite 216 Manassas, VA 20109•

6000 Executive Blvd, Suite 604, North Bethesda, MD 20852

Phone: 703 -729-3420 Fax: 703-729-3422 • www.ComprehensiveSleepCare.com

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LOUDOUN MEDICAL GROUP PC

NOTICE OF HIPAA PATIENT PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED

AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE

REVIEW IT CAREFULLY.

If you have any questions or comments about this Notice please contact:

Loudoun Medical Group, PC

224-D Cornwall St. N.W., Suite 403

Leesburg, VA 20176

Our Privacy Officer is: Clara McAuley Nussbaum, Director of Compliance, 703-737-6010

The following is the privacy policy (“Privacy Policy”) of Loudoun Medical Group, PC d/b/a Comprehensive

Sleep Care Center (“Covered “Entity”) as described in the Health Insurance Portability and Accountability Act

of 1996 and regulations promulgated there under, commonly known as HIPAA. HIPAA requires Covered Entity

by law to maintain the privacy of your personal health information and to provide you with notice of Covered

Entity’s legal duties and privacy policies with respect to your personal health information. We are required by

law to abide by the terms of this Privacy Notice.

Who Does this Notice Apply to?

Loudoun Medical Group, PC (“LMG”),

has published this Notice. It applies to

everyone who works for Loudoun

Medical Group, PC, including our

employees, contractors, and volunteers.

Why Do We Publish this Notice?

LMG understands that information about

you and your health is sensitive and

personal. We are required by law to

maintain the privacy of information we

gather and use about our patients, and

provide them with notices of our legal

duties and privacy practices with respect

to their information. We are also

required to notify affected individuals of

any breach of unsecured protected

health information.

While we are committed to the privacy of

our patients’ information, in order to

serve them we need to gather, keep and

use records of this information. We

sometimes also need to share

information with other parties. This

Notice is intended to let you know how

we use and disclose your information.

This Notice is also to let you know about

certain legal rights you have with respect

to the information we hold about you.

You have certain rights to review and

obtain a copy of our records of

information about you. You may also

request that we amend these records,

and may ask us to account for certain

disclosures we may have made of

information about you. Requests for

amendments and requests for

accountings must be made in writing

and directed to the Privacy Officer.

When Is This Notice Effective?

We are required to comply with the

terms of this Notice while it is in effect.

We reserve the right to change the

terms of this Notice, and make the new

terms effective for all information to

which this Notice applies. This Notice

will be in effect from May 20, 2013 until

the date we publish an amended Notice.

If we do publish an amended Notice, we

will notify you at your next visit. We will

also publish the amended Notice in our

offices, and will publish it on our web site

if we maintain one.

What Information Does this Notice

Cover?

This Notice covers all information in our

written or electronic records which

concerns you, your health care, and

payment for your health care. It also

covers information we may have shared

with other organizations to help us

provide your care, get paid for providing

care, or manage some of our

administrative operations.

When Can We Use or Disclose

Information About You?

· Treatment. We may use or disclose

information about you for treatment

purposes to doctors, nurses,

technicians, medical students or

other individuals who work in our

practice who are involved in

providing you with health care. We

may also disclose information about

you to organizations and individuals

involved in your care who are

outside of our practice, such as

consulting physicians, laboratories,

social workers, and so on.

For example, if we refer you to

another physician or a hospital for

specialty services, we will provide

that physician or hospital with all

clinical information, which might be

necessary or helpful to help them

provide you with the right care. Or, if

we need to send a sample of your

Diagnostic & Treatment Center for Sleep Disorders

19441 Golf Vista Plaza, Suite 230, Lansdowne, VA 20176 • 14141 Robert Paris Court, Chantilly, VA 20151 • 200 N. Glebe Road, Suite 316, Arlington, VA 22203

4897 Prince William Parkway, Suite 102, Woodbridge, VA 22192 • 3687 Fettler Park Drive, Dumfries, VA 22025

12321 Middlebrook Road, Germantown, MD 20874 • 8100 Ashton Ave., Suite 216 Manassas, VA 20109•

6000 Executive Blvd, Suite 604, North Bethesda, MD 20852

Phone: 703 -729-3420 Fax: 703-729-3422 • www.ComprehensiveSleepCare.com

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blood to a laboratory for analysis, we

will provide the laboratory with the

information they need to process

your blood correctly.

These are only examples, and we

may use or disclose information

about you to provide you proper

treatment in many other ways.

· Payment. We may use or disclose

information about you for payment

purposes to our clerks and officers

involved in billing and claims

payment. We may also disclose such

information to your health plan or

other party financially responsible for

your care, or to claims and billing

services if necessary.

For example, if you are covered by a

health plan we cannot get paid for

the services we provide you unless

we submit information in a claim.

This might include detailed clinical

information, depending on the kind of

plan and claim. This is only an

example, and there may be many

other ways in which we may use or

disclose information about you in

connection with payment for your

care.

· Health care operations. We may

use or disclose information about

you for operations in connection with

our practice. These activities might

include practice quality improvement,

training of medical students,

insurance underwriting, medical or

legal review, and business planning

or administration of our practice.

For example, we may wish to review

the quality of care you receive, in

order to help us deliver the best care

we can. Or, we may audit our

management practices so we can

become more efficient. These are

only examples, and we may use or

disclose information about you for

health care operations in many other

ways.

We may also use and disclose

information about you in the following

situations, without your prior

authorization:

· To a public health agency, for

purposes such as controlling

disease.

· In case of suspected child abuse, to

the appropriate governmental

authority.

· In other cases of suspected abuse,

neglect or domestic violence, to the

appropriate governmental authority,

with your agreement or if required by

law, or if you are incapacitated or it

appears necessary to prevent

serious harm to you or others.

· Unless you object, to friends or

family members who are involved in

your medical care.

· Unless you object, to notify, or to

assist in notifying, a family member

or friend of your location or condition.

· To health oversight authorities, for

regulatory, licensing and other legal

purposes.

· In litigation and legal proceedings,

subject to certain requirements

controlling the terms of the

disclosure.

· To law enforcement agencies,

subject to applicable legal

requirements and limitations.

· We may disclose health information

to the extent authorized by and to

the extent necessary to comply with

laws relating to workers’

compensation or other similar

programs established by law.

· To Funeral Directors/Medical

Examiners/Coroners in the event of

your death.

· When required by Federal, State or

Local law.

· For medical research purposes,

subject to your authorization or

approval by an institutional review

board or privacy board.

· If you are in the United States military,

national security or intelligence,

Foreign Service, to your authorized

superiors or other authorized federal

officials.

We may contact you for information to

support your health care, including

appointment reminders, information

about alternative treatments, and health-

related services, which may be of

interest to you. We will routinely contact

patients via telephone at home and/or

work and, unless otherwise requested,

may leave messages on the appropriate

voice mail or answering service

regarding appoint-ments. Please advise

us if you do not wish to receive such

communications, and we will not use or

disclose your information for such

purposes. If you wish not to receive this

kind of communication, you must advise

the Privacy Officer in writing at the

address given above.

Most uses and disclosures of

psychotherapy notes and most uses and

disclosures of your information for

marketing purposes will require your

written authorization. Further, LMG

would typically be required to obtain

your written authorization in order to sell

your information. Except for uses and

disclosures described in this notice, we

may not use or disclose information

about you for any other purpose without

your written authorization.

What Legal Rights Do You Have In

Connection With Your Information?

· Right to Inspect and Copy. You

have the right to inspect or obtain

copies of your medical information.

To inspect and copy medical

information, you must submit your

request in writing to the Privacy

Officer at the address set forth

above. If you request a copy of the

Diagnostic & Treatment Center for Sleep Disorders

19441 Golf Vista Plaza, Suite 230, Lansdowne, VA 20176 • 14141 Robert Paris Court, Chantilly, VA 20151 • 200 N. Glebe Road, Suite 316, Arlington, VA 22203

4897 Prince William Parkway, Suite 102, Woodbridge, VA 22192 • 3687 Fettler Park Drive, Dumfries, VA 22025

12321 Middlebrook Road, Germantown, MD 20874 • 8100 Ashton Ave., Suite 216 Manassas, VA 20109•

6000 Executive Blvd, Suite 604, North Bethesda, MD 20852

Phone: 703 -729-3420 Fax: 703-729-3422 • www.ComprehensiveSleepCare.com

- 11 -

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information, there will be a charge

based on our costs.

We may deny your request to

inspect and copy in certain very

limited circumstances. If you are

denied access to medical

information, you may request that

the denial be reviewed by another

licensed health care professional.

We will comply with the outcome of

the review.

· Right to Amend. If you feel that

medical information we have about

you is incorrect or incomplete, you

may ask us to amend the

information. You have the right to

request an amendment for as long

as we keep the information.

To request an amendment, your

request must be made in writing and

submitted to the Privacy Officer at

the address set forth above. In

addition, you must provide a reason

that supports your request.

We may deny your request for an

amendment if it is not in writing or

does not include a reason to support

the request. In addition, we may

deny your request if you ask us to

amend information that:

· Was not created by us, unless the

person or entity that created the

information is no longer available

to make the amendment;

· Is not part of the medical

information kept by or for LMG;

· Is not part of the information which

you would be permitted to inspect

and copy; or

· Is accurate and complete.

You will be informed of the decision

regarding any request for

amendment of your medical

information and, if we deny your

request for amendment, we will

provide you with information

regarding your right to respond to

that decision.

· Right to an Accounting of

Disclosures. You have the right to

request an accounting of disclosures

we have made of your medical

information. The accounting of

disclosures typically would not list

disclosures we made of medical

information about you that were

made for purposes of treatment,

payment, or health care operations

and that were made in response to a

specific authorization from you.

To request this list or accounting of

disclosures, you must submit your

request in writing to the Privacy

Officer at the address set forth

above. Your request must state a

time period for which you want the

accounting (which may not be longer

than six years prior to the request).

· Right to Request Restrictions. You

have the right to request a restriction

or limitation on the medical

information we use or disclose about

you for treatment, payment or health

care operations. You also have the

right to request a limit on the medical

information we disclose about you to

someone who is involved in your

care or the payment for your care,

like a family member or friend. For

example, you could ask that we not

use or disclose information about a

surgery you had.

We are not required to agree to a

requested restriction, unless (i) you

are requesting that we not disclose

information to a health plan for

payment or health care operations of

the health plan, and (ii) the

information pertains solely to an item

or service for which you or someone

other than the health plan has

already paid in full. If we do agree to

a requested restriction, we will

comply with your request unless the

information is needed to provide you

emergency treatment. Additionally,

even when we do not agree to a

requested restriction, health

information about you may only be

disclosed to family or friends if, in the

exercise of professional judgment,

we believe it is in your best interest

to have such information disclosed.

However, under such circumstances,

where practical, you will be given the

opportunity to object to any such

disclosure.

To request restrictions, you must

make your request in writing to the

Privacy Officer at the address set

forth above.

· Right to Request Confidential

Communications. You have the right

to request that we communicate with

you about medical matters in a

certain way or at a certain location.

For example, you can ask that we

only contact you at work or by mail.

To request confidential

communications, you must make

your request in writing to the Privacy

Officer at the address set forth

above. Your request must specify

how or where you wish to be

contacted.

· Right to a Paper Copy of This

Notice. You have the right to a

paper copy of this notice. You may

ask us to give you a copy of this

notice at any time. Even if you have

agreed to receive this notice

electronically, you are still entitled to

a paper copy of this notice.

· Complaints. If you believe your

privacy rights have been violated,

you may file a complaint with LMG or

with the Secretary of the Department

of Health and Human Services. To

file a complaint with LMG, contact

the Privacy Officer at the phone

number or address set forth above.

All complaints to the Department of

Health and Human Services must be

submitted in writing. We will not

retaliate against you for filing a

complaint.

Diagnostic & Treatment Center for Sleep Disorders

19441 Golf Vista Plaza, Suite 230, Lansdowne, VA 20176 • 14141 Robert Paris Court, Chantilly, VA 20151 • 200 N. Glebe Road, Suite 316, Arlington, VA 22203

4897 Prince William Parkway, Suite 102, Woodbridge, VA 22192 • 3687 Fettler Park Drive, Dumfries, VA 22025

12321 Middlebrook Road, Germantown, MD 20874 • 8100 Ashton Ave., Suite 216 Manassas, VA 20109•

6000 Executive Blvd, Suite 604, North Bethesda, MD 20852

Phone: 703 -729-3420 Fax: 703-729-3422 • www.ComprehensiveSleepCare.com

- 12 -

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Patient’s Full Name:

DOB: _____/_____/_____

Date: _____/_____/_____

Height:

Weight

Now:

Weight 1yr

Maximum:

1. Please tell us the main reason for your office visit or test with us:

 Snoring  Excessive daytime sleepiness  Leg movements during sleep  Difficulty falling/staying asleep

 Poor sleep-wake schedule  Disruptive behaviors during sleep  Other:

2. When did your sleep problem start? ___________________________________________________________________

3. Have you ever had an overnight sleep study (Polysomnogram)?  YES  NO

If yes, when and what did the results show?  Mild  Moderate  Severe

Any Periodic Limb Movement Disorder or Restless Leg Syndrome noted?  YES  NO

4. EPWORTH SLEEPINESS QUESTIONNAIRE

How likely are you to doze off or fall asleep in the 8 situations described below, in contrast to just feeling tired? This refers to your usual way

of life in recent times. Even if you haven’t done some of these things recently, try to work out how they would have affected you. Please use

the following scale to choose the most appropriate number for each situation:

0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing

SITUATION CHANCE OF DOZING

Sitting and reading 0 1 2 3

Watching TV 0 1 2 3

Sitting, inactive in a public place (e.g. a theatre or meeting) 0 1 2 3

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

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

Sitting and talking to someone 0 1 2 3

Sitting quietly after a lunch without alcohol 0 1 2 3

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

5. MEDICAL HISTORY Do you have known Medical Issues like, please check all of the following conditions that apply:

 Broken nose  Deviated nasal septum  Arthritis  Headache  Asthma  COPD  Nasal polyps Fibromyalgia

 Hypertension  Irregular heart rhythm  Emphysema  Chronic bronchitis  Diabetes  High cholesterol  Congestive heart failure 

Kidney disease  Acid reflux  Peptic ulcers  Thyroid disease  Neuropathy  Stroke  Seizures  Liver disease  Coronary Artery

Disease/Heart  Other: attack

6. MEDICATION (OPTIONAL, IF YOU HAVE TIME)

Please list all prescription and over-the-counter medications that you current use:

Name

Dosage

Frequency

Reason for Medication

________________________________________________________________ Date: _____/_____/_____

Patient / Guardian Signature

Diagnostic & Treatment Center for Sleep Disorders

19441 Golf Vista Plaza, Suite 230, Lansdowne, VA 20176 • 14141 Robert Paris Court, Chantilly, VA 20151 • 200 N. Glebe Road, Suite 316, Arlington, VA 22203

4897 Prince William Parkway, Suite 102, Woodbridge, VA 22192 • 3687 Fettler Park Drive, Dumfries, VA 22025

12321 Middlebrook Road, Germantown, MD 20874 • 8100 Ashton Ave., Suite 216 Manassas, VA 20109•

6000 Executive Blvd, Suite 604, North Bethesda, MD 20852

Phone: 703 -729-3420 Fax: 703-729-3422 • www.ComprehensiveSleepCare.com

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>VERY IMPORTANT INFORMATION TO READ PRIOR TO SLEEP STUDY FOR PREPARATION

A fee of $150 will be charged for cancellations or changes within 72 hours of an appointment

Please be aware of the location and suite you are scheduled for, and note the instructions for entry into the facility:

If you are scheduled for a sleep study and cannot enter the building please press 1 and select one of the following options: press 1 for

Woodbridge, press 2 for Arlington, press 3 for Lansdowne, press 4 for Chantilly, press 5 for Dumfries, press 6 for Manassas, dial direct for

Germantown (240) 238.2186, and dial direct for Bethesda (703) 293-5241.

***SHOULD YOU HAVE AN ISSUE WITH ENTRY INTO ANY OF OUR CENTERS, PLEASE CALL (571) 439-9848***

LANSDOWNE:

19441 Golf Vista Plaza, Suite 230, Lansdowne, VA 20176

Press 14491 on the keypad to enter the building.

CHANTILLY:

14141 Robert Paris Court, Chantilly, VA 20151

Proceed to the rear of the building to park. Directly enter the unit without access restriction

ARLINGTON:

200 N. Glebe Road, Suite 316, Arlington VA 22203

Proceed to the rear of the building to park. Press the # key associated with the Sleep Center

on the directory. Await the release of the door, and proceed to wait at the front of the

elevator, where a technician will arrive to escort you into the facility.

DUMFRIES:

3687 Fettler Park Drive, Dumfries, VA 22025

Proceed directly to enter the unit without access restriction

WOODBRIDGE:

4897 Prince William Parkway, Suite 102, Woodbridge, VA 22192

Please use your cell phone to call (703) 729-3420, and press 1 for one of our staff

MANASSAS:

8100 Ashton Avenue, Suite 216 Manassas, VA 20109

Please use your cell phone to call (703) 729-3420, and press 6 for one of our staff

GERMANTOWN:

12321 Middlebrook Rd, Germantown, MD 20874

Please use your cell phone to call (240) 238-2186

BETHESDA:

6000 Executive Blvd, Suite 604, North Bethesda, MD 20852

Proceed to the front of the building to park. Call Datawatch outside the building by pressing the button at

the front pedestal that houses ADA push pad. This is located directly to the right of the front door. A

Datawatch representative will answer and request for entry code. Your entry code is

“000620176”. Datawatch will then release the front door, and you should proceed to the elevators and call

the elevator to the sixth floor. If you need to speak technician on duty please use your cell phone to call

(703) 293.5241 and press 1 for one of our staff.

 Arrive to your designated sleep lab at your appointment time and no earlier than 9 PM on the night of your study.

 Please wash your hair prior to coming to the sleep center. Do not use hair sprays, cream rinses or conditioners.

Please do not apply makeup, nail polish, face or body cream/lotion, as they may interfere with electric sensors.

 Take all your regular medications, unless instructed by your physician to do otherwise. Keep a record of your

medications and the time taken. Please bring any medication that you may need to use during your stay.

 Please do NOT consume beverages or food containing caffeine after 12:00 p.m. on the day of the study.

 Try to get a full night of sleep the night prior to your study. Please do NOT take any naps the day of your study.

 Please bring nightclothes for the study. Loose fitting, cotton pajamas are preferred. Please avoid nightclothes that

are made of satin, nylon, or silk because the chemicals/pastes could damage them.

 Feel free to bring personal belongings to your study that may help your sleep more comfortably, e.g., favorite pillow,

blanket, book, etc.

 Bathrooms with shower stalls are available for your convenience at Arlington, Chantilly, Dumfries, Germantown and

Lansdowne. You may choose to bring a tooth brush, toothpaste, shampoo and soap for the morning to freshen up.

In addition, you may have to wash your hair several times to remove the paste from your hair used during the study.

 You are usually free to leave by 6:00-6:15 am.

Diagnostic & Treatment Center for Sleep Disorders

19441 Golf Vista Plaza, Suite 230, Lansdowne, VA 20176 • 14141 Robert Paris Court, Chantilly, VA 20151 • 200 N. Glebe Road, Suite 316, Arlington, VA 22203

4897 Prince William Parkway, Suite 102, Woodbridge, VA 22192 • 3687 Fettler Park Drive, Dumfries, VA 22025

12321 Middlebrook Road, Germantown, MD 20874 • 8100 Ashton Ave., Suite 216 Manassas, VA 20109•

6000 Executive Blvd, Suite 604, North Bethesda, MD 20852

Phone: 703 -729-3420 Fax: 703-729-3422 • www.ComprehensiveSleepCare.com

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SPECIAL INSTRUCTIONS FOR MULTIPLE SLEEP LATENCY (MSLT) TEST

1. The MSLT is usually performed the morning after an all night sleep study.

2. Continental breakfast and catered lunch are provided for this test.

3. Please bring reading materials to read during your stay with us.

4. The testing is usually concluded between 4:00-5:00 pm.

ADDITIONAL QUESTIONS IN PREPARATION FOR YOUR SLEEP STUDY – PLEASE CONTACT US AT 703-729-3420.

LANSDOWNE CENTER: 19441 Golf Vista Plaza, Suite 230, Lansdowne, VA 20176

Route 7 West:

 Take VA-7 West toward Leesburg/Winchester

 Exit onto Lansdowne Blvd. toward VA 2400 N/Lansdowne

 Turn left onto Riverside Parkway

 Turn Right onto Golf Vista Plaza

Route 7 East:

 Take VA-7 East toward Tyson’s Corner

 Exit onto Lansdowne Blvd. toward VA 2400 N/Lansdowne

 Turn left onto Riverside Parkway

 Turn Right onto Golf Vista Plaza

Route 28:

 Take VA-28 North toward VA-7 West toward

Leesburg/Winchester

 Exit onto Lansdowne Blvd. toward VA 2400 N/Lansdowne

 Turn left onto Riverside Parkway

 Turn Right onto Golf Vista Plaza

Diagnostic & Treatment Center for Sleep Disorders

19441 Golf Vista Plaza, Suite 230, Lansdowne, VA 20176 • 14141 Robert Paris Court, Chantilly, VA 20151 • 200 N. Glebe Road, Suite 316, Arlington, VA 22203

4897 Prince William Parkway, Suite 102, Woodbridge, VA 22192 • 3687 Fettler Park Drive, Dumfries, VA 22025

12321 Middlebrook Road, Germantown, MD 20874 • 8100 Ashton Ave., Suite 216 Manassas, VA 20109•

6000 Executive Blvd, Suite 604, North Bethesda, MD 20852

Phone: 703 -729-3420 Fax: 703-729-3422 • www.ComprehensiveSleepCare.com

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CHANTILLY CENTER: 14141 Robert Paris Court, Chantilly, VA 20151

Route 66 West:

 Take Route 66 West to Exit 53B VA-28 North

 Keep right at fork and Merge onto VA-28 North/Sully Road

 Take the Westfields Blvd exit toward County Road 662

 Keep right at fork and merge onto Westfields Blvd

 Turn right onto Walney Road

 Turn right onto Robert Paris Court

Route 50 West:

 From Route 50 West

 Turn left onto Walney Road

 Turn left to stay on Walney Road

 Turn right onto Robert Paris Court

Route 50 East:

 From Route 50 East

 Turn right onto Walney Road

 Turn left to stay on Walney Road

 Turn right onto Robert Paris Court

ARLINGTON CENTER: 200 N. Glebe Road, Suite 316, Arlington, VA 22203

Route 66 West:

 Take Route 66 West

 Exit 71 onto VA-120 Glebe

 Road Turn left onto N. Glebe Road

Route 66 West:

 Take Route 66 East

 Exit 71 for Fairfax Drive toward VA-120/VA-237/Glebe

Road Merge onto N. Fairfax Drive

 Turn right onto N. Glebe Road

Route 50 West:

 Take Route 50/Arlington Blvd. East to Glebe Road exit

 Turn Left at the traffic light onto N. Glebe Road Building is

on the Left hand side

Route 50 East:

 Take Route 50/Arlington Blvd. West to Glebe Road exit

 Turn Right at the traffic light onto N. Glebe Road Building

is on the Left hand side

Diagnostic & Treatment Center for Sleep Disorders

19441 Golf Vista Plaza, Suite 230, Lansdowne, VA 20176 • 14141 Robert Paris Court, Chantilly, VA 20151 • 200 N. Glebe Road, Suite 316, Arlington, VA 22203

4897 Prince William Parkway, Suite 102, Woodbridge, VA 22192 • 3687 Fettler Park Drive, Dumfries, VA 22025

12321 Middlebrook Road, Germantown, MD 20874 • 8100 Ashton Ave., Suite 216 Manassas, VA 20109•

6000 Executive Blvd, Suite 604, North Bethesda, MD 20852

Phone: 703 -729-3420 Fax: 703-729-3422 • www.ComprehensiveSleepCare.com

- 16 -

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WOODBRIDGE CENTER: 4897 Prince Wm Pkwy, Ste. 102, Woodbridge, VA 22192

From 95

 Merge onto 95 North

 Take Exit 152-B towards Manassas to merge onto VA-234 N

 Dumfries Rd towards Manassas – and go 4.0 miles

 Follow Spriggs Rd and State Rte 642/ Hoadley Rd to Prince

William Pkwy in Dale City – about 7.3 miles.

 Turn right onto Spriggs Rd and go 4.5 miles,

 Turn right onto State Rte. 642/Hoadly Rd and go 2.5 miles.

 Turn right onto Prince William Pkwy – Destination will be on

the right

 Make a U-turn onto Hoadly Road/VA-642 E and go 0.1 miles

Take the 1st right onto Prince Wm Pkwy/VA-294 S and go 0.3

miles

 If you reach County Complex Ct – You’ve gone about 0.1 miles

too far.

From 95 N

 Merge onto 95

 South Take Exit 163 for VA-642 towards Lorton

 Turn right onto VA-642/Lorton Rd for 1.3 miles, slight left onto

Lorton Rd, go 0.7 miles

 Turn left onto Ox Rd and go for 1.1 miles Continue onto VA-

123 S/Gordon Blvd Turn right onto Old Bridge Rd.

 Continue onto VA-294 W/Prince

 William Pkwy for 1.2 miles, Make a U-turn, destination will be

on right.

DUMFRIES CENTER: 3687 Fettler Park Drive, Dumfries, VA 22025

From 95

 Merge onto 95 North or South (if coming from Springfield)

 Take Exit 152 B to merge onto VA-234 N toward Manassas

 Turn left onto Van Buren Rd. and go 0.2 miles Turn left onto

Fettler Park Dr, Destination will be on the right

From 95 N

 Merge onto 1-95 N towards Washington, DC

 Take Exit 152-B and merge onto Dumfries Rd, VA-234 N

towards

 Manassas

Diagnostic & Treatment Center for Sleep Disorders

19441 Golf Vista Plaza, Suite 230, Lansdowne, VA 20176 • 14141 Robert Paris Court, Chantilly, VA 20151 • 200 N. Glebe Road, Suite 316, Arlington, VA 22203

4897 Prince William Parkway, Suite 102, Woodbridge, VA 22192 • 3687 Fettler Park Drive, Dumfries, VA 22025

12321 Middlebrook Road, Germantown, MD 20874 • 8100 Ashton Ave., Suite 216 Manassas, VA 20109•

6000 Executive Blvd, Suite 604, North Bethesda, MD 20852

Phone: 703 -729-3420 Fax: 703-729-3422 • www.ComprehensiveSleepCare.com

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GERMANTOWN: 12321 Middlebrook Road, Germantown, MD 20874

From 95

 Take I-895 S, I-95 S, MD-200 W and I-270 N to Middlebrook

Road in Germantown.

 Take exit 13B from I-270 N Merge onto Middlebrook Road

From 95 N

 Take I-95 N and I-495 N to Middlebrook Road in Germantown.

Take exit 13B from I-270 N

 Merge onto Middlebrook Road

MANASSAS: 8100 Ashton Ave., Suite 216 Manassas, VA 20109

From areas

below

Manassas

 66 E ramp to Washington 0.9 mi, Merge onto I-66 E 3.5 mi

 Take exit 47 for VA-234 N/VA-234 toward Manassas 0.1 mi

 Slight right onto VA-234 BUS S/Sudley Rd (signs for Virginia

234/Manassas) 0.9 mi

 Turn right onto Sudley Manor Dr 0.4 mi

 Turn left onto Ashton Ave

 Destination will be on the right

NORTH BETHESDA: 6000 Executive Blvd, Suite 604, North Bethesda, MD 20852

From areas

below

N. Bethesda

 Head northwest on I-495 W for 0.9 mile

 Keep right at the fork to continue on I-270 N, follow signs for

Frederick for 1.4 mile.

 Take exit 1A for MD-187/Old Georgetown Rd 0.1 mile

 Keep right at the fork, follow signs for Old Georgetown Rd

N/MD-187 N and merge onto MD-187 N/Old Georgetown Rd.

 Turn left onto Executive Blvd

 Turn left. The destination will be on the right.

Diagnostic & Treatment Center for Sleep Disorders

19441 Golf Vista Plaza, Suite 230, Lansdowne, VA 20176 • 14141 Robert Paris Court, Chantilly, VA 20151 • 200 N. Glebe Road, Suite 316, Arlington, VA 22203

4897 Prince William Parkway, Suite 102, Woodbridge, VA 22192 • 3687 Fettler Park Drive, Dumfries, VA 22025

12321 Middlebrook Road, Germantown, MD 20874 • 8100 Ashton Ave., Suite 216 Manassas, VA 20109•

6000 Executive Blvd, Suite 604, North Bethesda, MD 20852

Phone: 703 -729-3420 Fax: 703-729-3422 • www.ComprehensiveSleepCare.com

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SLEEP STUDY FAQ’S

1. What is a sleep study?

A sleep study is a non-invasive test where your brain waves and sleep patterns are monitored by a trained sleep technician. While you

sleep, we collect data that will help us understand your sleep better. Based on the results, a personalized treatment plan is developed by or

board-certified sleep physicians and your follow-up appointment with our sleep specialist or your referring physician will be the next step.

2. What is involved in a sleep study?

A sleep study is completely painless. Sticky patches called sensors are placed on your scalp, face, chest, limbs and a finger. While you

sleep, these devices record your brain activity, eye movements, heart rate and rhythm, blood pressure, and the amount of oxygen in your

blood. Elastic belts are placed around your chest and abdomen. They measure chest movements and the strength and duration of each

exhaled breath. The wires will be attached to sensors that transmit data to a computer in the next room. The wires are very thin and flexible

and are bundled together to minimize discomfort. You will be able to roll in any direction. Although we call the procedure of attaching these

items the “hook-up” process, there are no hooks involved and no needles. The hook- up is not painful and is designed to be as comfortable

as possible. Many people ask us how they will be able to sleep while connected to these sensors and belts. Most people find that once they

lie down in bed, they do not notice the wires and can sleep in a variety of positions comfortably. The sensors are gathered into a “pony tail”

above your head so that you can change position in bed almost as easily as you would at home. The technician will explain all the

procedures and will be happy to answer your questions about the study.

3. Are sleep studies safe and are they comfortable?

Yes, sleep studies are safe. We simply monitor your brain and muscle activity, sleeping position, and breathing while you are sleeping.

There are no needles, drugs or other invasive procedures. Well-trained sleep technologists will monitor your entire sleep-testing period from

a nearby room. As for the comfort level, we do our best to make your stay comfortable. However it may feel a bit awkward. You will stay in a

private, comfortable, home-like bedroom with plush bedding. You can wear your usual bed clothes and you may bring your own pillow if you

prefer. You can read at bedtime or watch TV. For many, our private, comfortable, home-like setting is preferred over a hospital environment.

4. Why do I have to stay overnight?

Overnight sleep studies are the “gold standard” used for accurately diagnosing sleep disorders. Overnight studies are necessary in part

because sleep patterns may vary throughout the night. In addition, overnight studies are important for detecting more subtle symptoms

5. If I work the night shift can I come in during the day?

Yes. Ideally the sleep study will occur during your normal sleeping time.

6. What time do I need to be at the center for my sleep study?

For our adult patients we ask that you when you schedule your exam you schedule it based on two arrival time slots, the first one is to

arrive at 9 pm, and the second slot is at 9:45 pm. This is to ensure our technologists can assist you in your needs and setup with ample in a

relaxed manner as it takes some time for you to settle in. Pediatric patients are welcome to arrive at 8:30 pm.