Refer a new patient – collincountysleep

Patient Name:

Patient Tel #:

Patient Address:

Insurance Carrier:

Member ID #:

Insurance Tel #:

Patient DOB:

EPWORTH SLEEPINESS SCALE:

How likely are you to doze off or fall asleep in the following situations, as compared to just feeling tired? Even if you have not done some of these things recently, try to answer how you think you would be affected? Use the following scale: 0 = would never doze 1 = slight chance 2 = moderate chance 3 = high chance of dozing

Type of Sleep Study Requested:

Polysomnography (PSG: Baseline Sleep Study- All night sleep recording) Insurance Billed If PSG is denied by Insurance, then HST will be performed

Home Study (HSAT)-Home Sleep Apnea Test- Insurance Billed (2 nights for most insurance, 1 night Medicare)

Home Study (HSAT) – Cash (349.00 total) 2 nights

Split Polysomnography (Diagnostic and treatment with CPAP/Bi-Level)

Polysomnography with CPAP/Bi-Level/ASV all night (Titration Treatment)

Multiple Sleep Latency Test (MSLT) (Rule out Narcolepsy has to be done following a baseline sleep study. Maintenance of Wakefulness Test (MWT)

EEG (21-channel data collection for TIA’s, Seizures, Epilepsy: non-respiratory concerns

Inspire Fine Tuning

Oral Device Titration

Additional Comments:

History and physical: (Please check any of the following that apply):

Name:

Referring Physician: *Please attach clinical notes and recent sleep study*

Address:

NPI:

Tel #:

Fax #:

Signature:

Date:

Frisco