American Sleep Centers Patients Intake Form 2

User Manual: american-sleep-centers-patients-intake-form-2

Open the PDF directly: View PDF PDF.
Page Count: 1

DownloadAmerican-sleep-centers-patients-intake-form-2
Open PDF In BrowserView PDF
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: __________



Source Exif Data:
File Type                       : PDF
File Type Extension             : pdf
MIME Type                       : application/pdf
PDF Version                     : 1.7
Linearized                      : Yes
Author                          : mcuevas
Create Date                     : 2018:01:22 13:36:11-08:00
Modify Date                     : 2018:01:22 13:55:37-08:00
Language                        : en-US
Tagged PDF                      : Yes
XMP Toolkit                     : Adobe XMP Core 5.6-c015 84.159810, 2016/09/10-02:41:30
Producer                        : Microsoft® Word 2016
Format                          : application/pdf
Title                           : 
Creator                         : mcuevas
Creator Tool                    : Microsoft® Word 2016
Metadata Date                   : 2018:01:22 13:55:37-08:00
Document ID                     : uuid:2236C276-B06D-4BDE-964D-31F51A357B3E
Instance ID                     : uuid:58f38b92-2496-4d3c-9466-35e8b28eeae0
Page Count                      : 1
EXIF Metadata provided by EXIF.tools

Navigation menu