American Sleep Centers Patients Intake Form 2
User Manual: american-sleep-centers-patients-intake-form-2
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American Sleep Centers 9439 Archibald Ave. Suite 105 Rancho Cucamonga, CA 91730 Sleep Medicine Referral Form Phone: (866) 987-1611 Fax: (909) 987-5510 PATIENT NAME:____________________________________________________ DOB: ________ SS#________________ Last First MI ADDRESS:_________________________________City:_________________________State:_______Zip:______________ HOME:_____________________ CELL: ________________ CELL CARRIER: ____________EMAIL:___________________ Height: _________ Weight: ________ Neck Circumference: __________ Oxygen Use (Y/N): _______ Sex: (M/F): ______ INSURANCE: □ Medicare □ Work Comp □PPO Name of Insurance Company__________________________________ Policyholder ID#_____________________________________________ Please attach patient’s clinical history, medications, physician’s notes, demographics, & insurance information Referring Physician: ____________________________________________ NPI: _____________________________________ Address: ____________________________________ City: ____________________________ State: _____ Zip: ___________ Phone: _______________________ Fax: ___________________ Email: ___________________________________________ SYMPTOMS & REASON FOR REFERRAL Witness/Suspected Sleep Apnea Hypertension Snoring Excessive Daytime Sleepiness Morning Headaches Obesity Cardiac Disease Type ______________ COPD Diabetes Periodic Limb Movement Disorder Restless Leg Syndrome Narcolepsy Insomnia Parasomnia SLEEP DISORDERS DIAGNOSTIC SERVICES Comprehensive Sleep Study/Evaluation: by Board Certified/Eligible Sleep Specialist to determine and order appropriate testing procedure. (CPT 95810, 95811, 99204, 99214, or 99215) PSG: Full night in lab diagnostic polysomnography attended by a technologist. (CPT 95810) Split PSG: Full night in lab diagnostic polysomnography attended by a technologist with PAP, oxygen, or oral appliance titration. Please attach previous diagnostic sleep test. (CPT 95811) Full PSG Titration: Full night in lab polysomnography attended by a technologist with PAP, oxygen, or oral appliance titration. Please attach previous diagnostic sleep test. (CPT 95811) MSLT/MWT: Multiple Sleep Latency Test/Multiple Wakefulness Test used to rule out narcolepsy. Note: If patient meets diagnostic and procedural protocol, PAP titration will be performed and MSLT cancelled. (CPT 95805) Home Sleep Test (HST): If clinical criteria is met, diagnostic sleep test primarily to diagnose obstructive sleep apnea. (CPT 95806 or 95800) Special Requests: __________________________________________ DME Preference: ____________________________ Physician Signature: ___________________________ Date: ____________ Direct Referral: __________
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