Date:    DOB:

 Patient Name:

 Phone (home)     Phone (work)

Check all the apply-
Requested Procedure:

     Sleep Study -1st Night 95810        CPAP Titration 95811

     Multiple Sleep Latency Test 95805   Overnight Sleep Oximetry Study 94762

     Other (Please specify) 

Pertinent Diagnoses and ICD-9-CM code and/or Symptoms

       Sleep Apnea 780.57       COPD 496       Hypertension 401.9

       Hypersomnia 780.54      Obesity 278.00  Hypoxemia 799.0

       Hypersomnia with Sleep Apnea 780.53    Narcolepsy 347 Congestive Heart Failure 428.0

       Snoring 786.09    Somnolence 780.09

       Other

       Other

Interpreting Physician

1st Available Interpreting Physician

   Richard Hammond, M.D.    Brian Fortuin, M.D.     John Pilch, M.D.     Ronald Fullmer, M.D.

   Reason for Referral:

Is Patient currently on Qxygen: Yes No

If Yes, LPM     Continuous     PRN    NOC

   Has Patient had previous sleep studies performed: Yes  No
   If Yes, Where and Date of Study:

  Would you like Patient to have a consultation with a Sleep Institute Physician? Yes  No

   Referring Physician's Signature:

   Physician's Name:

Please send before study is performed a copy of the patient's current history and physical, and any pertinent  lab information such as ABG, CBC, EKG results and any recent doctor's note indicating a reason for sleep study. 

We will supply you with a release form.
Copy of report will be faxed to your office no later than two weeks after study has been performed.

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