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Sleep Center Referral

 

 

 

 

 

Download Night & Day Sleep Referral form pdf icon Sleep Center Referral

 
Gender:  
Patient Name :     DOB :  
Phone (Home):     (Mobile/Work):  
Address :  
Primary Insurance :     Subscriber ID:  
Secondary Insurance :     Subscriber ID:  
 
SERVICES REQUESTED (This patient is being referred for):

SLEEP CONSULT

  Sleep Consultation & Management: Sleep Specialist to manage testing, treatment, and follow-up.

SLEEP TESTING ONLY (Referring physician will manage treatment and follow-up):

 PSG (95810) and a follow-up CPAP Titration (95811) (If PSG is positive, I authorize CPAP titration)

 PSG (95810) (Diagnostic test to rule out Sleep Apnea or other sleep disorder)

 CPAP (95811) (Titration of CPAP or Bi-level PAP setting to alleviate OSA)

 SPLIT Night (95811) (Diagnostic sleep study with CPAP titration if OSA is detected, > 30 events)

 MSLT (90805) (Daytime nap test following a full night diagnostic PSG to measure daytime sleepiness or diagnose narcolepsy)

 MWT (95805) (Daytime nap test to measure patient’s ability to remain awake)

Other:

 

INDICATION(S)
 Loud snoring
 Gasping or choking  during sleep
 Apneic episodes witnessed
 Excessive daytime sleepiness/fatigue
 Restless Leg Syndrome
Obese (BMI > 35.0)/Large neck(>15.75 in)
 Non-Restorative Sleep
 Sleep Disturbance
 Difficulty falling asleep
 Depression/Anxiety
 Crowded Oropharynx
 Enlarged Uvula and/or Soft Palate
 Enlarged tongue
 Enlarged tonsils
SUSPECTED DISORDERS
 Narcolepsy
 Periodic Limp Movements of Sleep (PLMS)
Obstructive Sleep Apnea (OSA)
 Insomnia
Other:

 

 

 

SPECIAL NEEDS
Nocturnal O2: L/pm
Interpreter, Language:
Wheelchair:
Urinal:
Other:

 

 

 

 

 

 

 

MEDICAL HISTORY HX MEDICATIONS
 Chronic lung diseases
 Heart disease
 Hypertension
 Thyroid disease
 Pre-operation (bariatric surgery)
Referring Physician: Appointment:
Address: Date:
Phone: Time:
Fax: Preferences:  Email Fax Mail
Email:        
       
Online Referral Consent Agreement
 Please send me a copy of this form.
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