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: __________