Sleep Center Referral Form for McLaren Greater Lansing

Sleep Center Referral Form

Note: Fields marked with an * indicates required field


Patient Name: *
Street Address: *
City: *
Zip Code: *
Home Phone (With Area Code): *
Work Phone:
Social Security Number: *
Date of Birth: *
Complaints/ Symptoms Noted:	Snoring Restless Sleep Depression Other Excessive Sleepiness Nocturnal Choking Memory Problems Morning Headaches Insomnia Hypertension Congestive Heart Failure Fatigue Post-Op Re-evaluation of CPAP/BIPAP
Please mark if the patient has any of the following:	HF (heart failure) NYHA Class III and IV, EF (ejection fraction) less than 50 percent, or Class II Diastolic Dysfunction Cardiac arrhythmia (e.g. atrial fibrillation, SVT, ventricular arrhythmia) Moderate to severe pulmonary disease( e.g. chronic respiratory disease / symptomatic lung disease / pulmonary hypertension) Neuromuscular disease diagnosis Neuromuscular disease diagnosis Cognitive impairment or other social circumstances that compromise administration of a home sleep test (HST) Stroke within the last 6 months Suspicion of other sleep disorders such as; Narcolepsy, idiopathic hypersomnia, periodic limb movement disorder, parasomnia, central sleep apnea, restrictive lung disease related to obesity, severe insomnia, obesity hypoventilation syndrome with BMI greater than 45 Less than 18 years of age Two failed Home Sleep Tests with significant indicators of obstructive sleep apnea Note:Add the following comment to the form: If any box is checked in this section the patient most likely will NOT qualify for an OCST (at home study) due to their comorbidities and complexity of their condition. OCST may not be reliable in these cases. An in-lab study is recommended. Please verify with the patient's insurance company.
Type of Study: *	95810 - Baseline/Diagnostic In-lab Sleep Study 95811 - Titration In-Lab Study 95805 - Multiple Sleep Latency Test (MSLT) to diagnose Narcolepsy or assess unexplained sleepiness 95805 - Maintenance of Wakefulness Test (MWT) to assess daytime alertness 95806 - Out of Center Sleep Testing (OCST) performed at home 94762 - Overnight Home Oximetry at home 94660-PAP Desensitization or Assistance Session (for person with claustrophobia, anxiety or having difficulty with their PAP equipment 94660 -AutoPAP trial (at home, if able to complete OCST, and required by insurance in lieu of in-lab titration.)
Office Contact: *
Comments:
Ordering Physician: *
Physician Phone Number: *
Physician Electronic Signature of NPI Number: *
Copy to Physician: *
Requestor Name:
Requestor Email Address: *
Insurance:
Insurance carrier: *
Pre-authorization number:
If the patient *	Pre-Authorized number is needed Patients insurance does not require a pre-authorization Unable to obtain pre-authorization at this time. Will forward when we receive.