Clone of Home Sleep Study Order Form

IN-LAB SLEEP STUDY ORDER
PATIENT INFORMATION
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Sex*
Phone Number:*
E-mail
Patient will receive confirmation email with appointment details
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company*
Insurance Policy #*
Please Upload Insurance Card Image if possible*

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REFERRING PROVIDER INFORMATION
Provider Name*
Provider NPI Number*
Provider Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Office Phone *
Please enter a valid phone number.
Office Fax*
Please enter a valid fax number.
Provider Email
Please provide an email if you wish to receive confirmation that this referral has been successfully submitted to Athens Pulmonary & Sleep Medicine.
PATIENT HEALTH INFORMATION

Symptoms/Indications for Testing
Please select ALL symptoms that apply:*

SnoringWitnessed ApneaExcessive Daytime SleepinessObesity (BMI>30)Awakens Gasping/ChokingMorning HeadachesHypertensionNon-Restorative SleepImpaired Cognition (Poor Memory & Concentration)Other
Please indicate the TYPE of In-Lab Study requested:*

Diagnostic NPSGCPAP TitrationBIPAP TitrationASV TitrationInspire TitrationNPSG/MSLTCPAP/MSLTOther
Please upload diagnostic sleep study.

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In addition to diagnosis code G47.33 (Obstructive Sleep Apnea), please indicate any additional diagnosis codes that may apply
Other Diagnosis Codes
Please indicate if any of the Contraindications for home sleep testing apply. This information may be necessary in order to get insurance approval for an In-Lab Study.
Please select ALL that apply:*

NoneCOPDCongestive Heart Failure (CHF)Neuromuscular ImpairmentStroke HistorySignificant Cardiac DiseaseRestless Leg SyndromeOther Suspected Sleep DisorderUses Supplemental OxygenOther
Other Clinical Information
This referral cannot be processed until the patients most recent office note or H&P has been received by Athens Pulmonary & Sleep Medicine.
Please Upload Office Notes and/or H&P*

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TESTING / TREATMENT PLANS
Please Choose Follow-up Option*
This referral form constitutes an order to perform a diagnostic sleep study.

After the sleep study, please indicate below how you would like for us to handle the follow-up and treatment plan for this patient.
Ordering Provider Statement

I am requesting a diagnostic sleep study for this patient. I certify that, to the best of my ability, I have accurately answered all questions on this referral form and submit this referral form as an executable order for a diagnostic sleep study. I understand that this referral cannot be processed until the patient's most recent office note or H&P has been received by Athens Pulmonary & Sleep Medicine. Please follow the instructions indicated above to coordinate the follow-up and treatment plan for this patient.
Signature*
Please type your name above as your electronic signautre.
DISCLAIMER: By typing your name above, you are signing this Order electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this sleep study order.
Should be Empty:

PATIENT INFORMATION

REFERRING PROVIDER INFORMATION

PATIENT HEALTH INFORMATION

TESTING / TREATMENT PLANS