Patient Name

DOB

Patient Phone

Patient Work Phone/Cell Phone

Address

City, State, Zip

Other Contact

 Special Needs 

Referring Physician

Person Completing Referral Consult

 Street Address

City, State, Zip

NPI                                                     Specialty

Phone Number

Fax Number

Insurance

Pre-Cert if required

Benefit Phone Number

Policy Number                          

Group Number

Name of Insured

Relation to Patient

Indication for testing/Diagnosis

□  Snoring                         □  OSA                           □ Apnea                             □  Daytime Sleepiness                    

□  Insomnia                       □  RLS/PLMS                □  Narcolepsy

□  Other Describe:

Please order requested procedure by checking the appropriate box below

□  CONSULT WITH PHYSICIAN, SLEEP STUDY & TREATMENT

OR

□   SLEEP STUDY ONLY – WITHOUT CONSULT (Check appropriate box below)

      PLEASE FAX US:      1) Recent office notes with clinical indications for disorder

                                         2) History and physical

Please order requested procedure by checking the appropriate box below:

□ Diagnostic Sleep Study (Polysomnogram) (CPT 95810, 95810-26)

(Urgent CPAP may be applied per established protocols)

□ Nasal CPAP Titration Sleep Study (CPT 95811, 95811-26)

(Previous diagnostic sleep study required)

□ Split Night Sleep Studies (CPT 95811, 95811-26)

(Patient must meet protocol)

This form will serve as a prescription for the services you have ordered.  If you have any questions regarding these requirements please contact our office at 505-438-3101

Signature of Physician

Date