Sleep Study Prescription Referral Form

After submitting this form, please fax a copy of the patient's most recent History and Physical information or office notes to
(914)333-5925.

The field descriptions in RED text are required.

Sleep Center:

Patient Information
First Name: Last Name:
Date of Birth:
MM
/
DD
/
YYYY
 
Address:
Address 2:
City: State:
Zip:
Phone:
E-mail:

Referring MD Information
Name:
Phone: Fax:
NPI: NPI Lookup

Primary Care MD Information
Name:
Phone:

Insurance Information
Insurance Carrier:
Policy ID#:

Test Requested
PSG (95810) and follow-up CPAP Titration (95811)
(If PSG is positive, I authorize CPAP Titration)

Polysomnography (PSG) (95810)

CPAP Titration (95811)

Split-Night study (1/2-PSG, 1/2-CPAP Titration) (95811)

PSG with Multiple Sleep Latency Test (MSLT) (95805)

PSG with Maintenance of Wakefulness Test (MWT) (95805)

PAP-NAP (95807-52)

Currently on CPAP/BIPAP? NO YES


Sleep Consult (optional)
I request a consult with a sleep specialist BEFORE the study
I request a consult with a sleep specialist AFTER the study

Indications (Check off all that apply)
Snoring (786.09)
Witnessed Apnea (327.20)
Daytime Sleepiness (327.1)
Periodic Limb Movement Disorder (327.51)
High Blood Pressure (401.9)
Shortness of Breath (786.05)
Arrhythmia (427.9)
Obesity (278.0)
Chronic Lung Disease (491.2)
Post-Op ENT Surgery
Pre-Bariatric Surgery

Additional Information (Special Requests, Patient Special Needs)

After submitting this form, please fax a copy of the patient's most recent History and Physical information or office notes to
(914)333-5925.

You may also attach and upload the patient's most recent History/Physical/Office Notes here:


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