theSleepMD Provider Referral Form
Patient Information
Patient Name
*
First Name
Last Name
Patient Email
*
example@example.com
Patient Phone Number
*
Please enter a valid phone number.
Back
Next
Patient Physical Exam & Sleep History
Weight (lbs)
*
Height (inches)
*
BMI (auto calculated)
Sleep Epworth Score (0-24)
*
Check all that apply
*
Sleep Disordered Breathing
Loud Snoring
Depression
Oral Appliance Assessment
Non-Restorative Sleep
Gasping / Choking
Excessive Daytime Sleepiness
Morning Headaches
Dry Mouth in A.M.
Insomnia
Observed Apneas
Cardiopulmonary / Upper Airway Exam
Check all that apply
*
Nasal Obstruction
Over / Under Bite
Teeth Worn
Enlarged Tongue
Maxillomandibular Abnormalities
Crowded Hypopharynx
Crowded Oropharynx
Enlarged Tonsils
Obesity
Hypertension
Retrognathia / Micrognathia
None
Diagnostic Codes
Check all ICD-10 codes that apply
*
G47.00 Insomnia, unspecified
G47.10 Hypersomnia, Unspecified
G47.30 Sleep apnea, Unspecified
G47.33 Obstructive sleep apnea (adult) (pediatric)
Back
Next
Home Sleep Test Procedure
2-nights unattended, Portable Recorder with minimum four (4) channels, for example: Records airflow, respiratory effort, Oz saturation and heart rate. Performed on room air unless specified below.
Select the appropriate test procedure
*
Home Sleep Test Comprehensive Sleep Evaluation
Home Sleep Test with Room Air (HST)
Home Sleep Test with Oxygen (LPM Needed)
Home Sleep Test with PAP (PAP Pressure Needed)
Home Sleep Test with Oral Appliance
Home Sleep Test with DOT certification
Home Sleep Test for pediatric patient ages 2-17
Home Sleep Test with Oxygen LPM:
Home Sleep Test with PAP details:
*
Back
Next
Referring Provider Information
Select a Referring Provider
*
Please Select
Cardiac Solutions
Cookeville Medical Center
Finger Lake Dental Care
Home Sleep Experts
Kind Dental Care
Pulmonary & Critical Care Professionals DFW
Ravin Chodavadia DDS
Thompson Advanced Dentistry
If not available, select OTHER
Back
Next
New Referring Provider
Referring Provider Name
Referring Provider Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Referring Provider Phone Number
Please enter a valid phone number.
Referring Provider Fax Number
Please enter a valid phone number.
Referring Provider Email
example@example.com
Referring Provider NPI
Back
Next
Prescriber Signature & Certification
I, the undersigned, certity that I am the patient's treating prescriber and that the information contained on this form is based on a face-to-face office visit. I am prescribing a two-night serial HST as medically necessary to validate results because of night to night variability.
Type a question
Date Signed
-
Month
-
Day
Year
Date
Submit Referral
Submit Referral
Should be Empty: