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
Snoring
Excessive Daytime
Sleepiness
Morning Headaches
Hypertension
Obesity
Diabetes
Cardiac Disease
Type ______________
COPD
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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