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Electronic Patient Referral Form
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Note: When providing an enlarged copy of Patient's Insurance Card and/or Patient Demographic/Insurance. information is not necessary to complete entire form.

ELECTRONIC FORM
*Required Fields

Patient Name:      SS#: Call to submit SS# via Phone

Address:      DOB:

City:      State:      Zip Code:

Home/Phone:      Sex: M F     Height:      Weight:

Work/Mobile:      Email Address:

Primary Insurance: HMO PPO POS EPO MMA None

Name of Insurance Plan:

Referring Provider:

Phone Number:      Fax Number:

City:      State:      Zip Code:     

I AUTHORIZE THE FOLLOWING SLEEP STUDY TO BE PERFORMED AT THE GRAND HEALTH INSTITUTE FACILITY (CHECK ONE):

1) Evaluate and Treat (CPT 95810 & 95811) Polysomnography, with 2nd night CPAP Titration, if indicated.
2) Polysomnogram (PSG) (CPT 95810) 1st Night Diagnostic Study for Evaluation Only.
3) CPAP / BiPAP Titration (CPT 95811) 2nd Night Titration following Diagnostic Study with DX of:
4) Follow up CPAP Titration (CPT 95811) For Patients currently using CPAP therapy.
5) Split Night Study (CPT 95811) Initial Diagnostic period followed by RDI > 40. CPAP initiation for:
6) MSLT (CPT 95805) Daytime Nap Study for EDS (PSG performed the preceding night).
7) Consultation with a Sleep Specialist Evaluation and Management of Patient for Sleep Complaints.
8) Consultaion with a Pulmonologist Evaluation and Management of Patient for Pulmonology.

THIS SLEEP STUDY IS MEDICALLY NECESSARY BECAUSE THE PATIENT IS EXHIBITING THE FOLLOWING SYMPTOMS:
Order must have at least one primary diagnosis.

PRIMARY DX
1) 327.23 OSA - Witnessed breathing pauses during sleep
2) 780.54 Excessive Daytime Sleepiness/Hypersomnia
3) 780.52 Insomnia of unknown etiology
4) 347.00,01 Narcolepsy - Daytime sleep attacks
5) 780.51 Insomnia with apnea
6) 327.51 Periodic limb movements during sleep
7) 333.94 Restless legs while falling asleep
8) Other  / If Other Selected, Please Explain:

SUPPORTING DX
1) 786.09* Loud or Disruptive snoring
2) 780.09* Somnolence or Drowsiness
3) 780.79* Fatigue or Malaise
4) 278.00* Obesity
5) 278.01* Morbid Obesity
6) 307.45* Shift Work Disorder
*Must include a PRIMARY DX.

Previous Sleep Study Yes No      When      Where:

Currently on CPAP: Yes No      Since When:      Pressure:

Special Instructions:


Provider Name:      Date:

Provider Digital Signature (Enter Your Initials):
Note: Entering your signature initials = equals your official signature.

    

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