Sleep Medicine Referral Form And Icd-10 Codes For Services - Sleepdata
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1
2Mission Valley Location
Oceanside Location
4420 Hotel Circle Ct. #240
3156 Vista Way #150
San Diego, CA 92108
Oceanside, CA 92056
FAX
619-299-6222
PHONE
619-299-6299
TOLL FREE
800-619-4672
M-F 8:00AM - 5:00PM
M-TH 8:30AM -4:30PM
Sleep Medicine Referral Form & ICD-10 Codes for Services
Please include as much information as possible regarding the patient and attach any of the patient’s clinical history, insurance info, and demographics.
Section 1: Patient Information (required)
PATIENT NAME:
REFERRING PHYSICIAN:
ADDRESS, CITY, STATE, ZIP:
ADDRESS, CITY, STATE, ZIP:
DOB:
FAX:
PHONE:
HOME PHONE:
CELL PHONE:
EMAIL:
WORK PHONE:
CA LICENSE:
NPI:
Section 2: Symtoms & Reason For Referral (required)
Witnessed/Suspected Sleep Apnea
Hypertension
Snoring
Diabetes
Obesity
Excessive Daytime Sleepiness
Cardiac Disease
Mood Disorder
Morning Headaches
COPD
History of OSA (G47.33)
Stroke
Section 3: Sleep Disorders/Diagnostic Services (required)
Baseline Home Sleep Test (HST): Diagnostic sleep study primarily to diagnose obstructive sleep apnea. (CPT 95806 or G0399)
As an efficacy Home Sleep Test (HST): on PAP, O
and/or oral appliance to ensure efficacious treatment (CPT 95806 or G0399)
2
Please initiate CPAP/Bilevel treatment if positive for OSA. (E0601, E0470 or E0471 and associated supplies)
Please evaluate current CPAP/Bilevel device and provide associated supplies.
Please initiate oral appliance therapy for OSA. (E0486)
CPAP_________________+/-2, APAP________—_________+/-2,
Bi-Level______________/______________ +/-2
PRACTITIONER SIGNATURE
SPECIAL REQUESTS
DATE
PATIENT INSURER NAME AND INSURANCE ID#
SLEEP DATA TAX ID #45-2683127
SLEEP DATA DIAGNOSTICS TAX ID #46-2155766
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