SLEEP TESTING ORDER FORM

Sleep Study Order Form
PATIENT INFORMATION

Gender: MGender: F
Full Name
Date of Birth

MonthDayYear
Date
Address

Address

Street Address Line 2

CityState

Zip
ROOM#
Language (if not English)
Height (ft) or (inches)
Weight
BMI
Skilled Nursing Facility
Hospital
Assistant Living Facility
Requested Test Date

MonthDayYear
Date
Requested Test Date

Patient discharging in the next 48 hours
Physician Full Name
NPI
Address

Address

Street Address Line 2

CityState

Zip
Email
example@example.com
Phone
Fax
SIGNS & SYMPTOMS (Choose 2 below circle)

List at least two of the symptoms below observed / reported during the patient’s visit

that included Vital Signs, HEENT, Neurological and Cardio / Pulmonary assessment.
DIAGNOSIS (Choose 1 suspected Dx below)

327.23 Obstructive Sleep Apnea780.53 Hypersomnia780.51 Insomnia with Sleep ApneaChronic SnoringMorning HeadachesAbrupt awakening during the night780.57 Other and Unspecified SleepApneic EventsAwaken with SOBDifficulty staying asleepOther ICD-9:NocturiaAwaken w/ dry mouthExcessive Daytime Sleepiness
TEST ORDERED:
L/M flow rate if test to be done on Oxygen (Note:Sleep Lease Corp. does not provide Oxygen)

Home Sleep Test. Unattended Type III (Records Airflow, Respiratory Effort, Pulse, O2 Saturation) on room air Indicate
L/M flow rate if test to be done on Oxygen (Note:Sleep Lease Corp. does not provide Oxygen)
PHYSICIAN SIGN & DATE (A stamped signature is not considered a valid order)

I am ordering a Home Sleep Test for the patient listed above. I certify this patient was evaluated during an office visit and demonstrated signs and symptoms consistent with Obstructive Sleep Apnea that requires Home Sleep Testing for evaluation. I further attest the evaluation was documented in the patient’s chart notes prior to ordering this test.
Signature

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PLEASE FAX THIS ORDER TO (888)-680-3008

Office (888)-657-6662
Should be Empty:

Sleep Study Order Form

TEST ORDERED:

PLEASE FAX THIS ORDER TO (888)-680-3008