Patient Information Form (Required For Scheduling) - Dekalb Medical

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Patient Information (Required for Scheduling)
Patient Name: _________________________________ DOB: _________________ Sex: ❑ M ❑ F SS#: XXX-XX- ___________
First & Last Name
Patient's Address: _________________________________ __________________________ ______________ _________________
Street
City
State
Zip Code
Home Phone#: __________________ Mobile Phone #: ___________________ Email Address: ___________________________
Primary Insurance: __________________________ Policy #: ______________ Group #: __________ Phone #: ______________
Plan & Product
Secondary Insurance: _______________________ Policy #: ______________ Group #: __________ Phone #: ______________
Plan & Product
Order Information - Sleep Disorder Center
Presenting Symptoms:
❑ Loud snoring
❑ Non-restorative sleep
Other (please specify): _______________________
❑ Observed apnea
❑ Limb restlessness/jerks
❑ Excessive daytime sleepiness
❑ Sleep paralysis or cataplexy
❑ Difficulty initiating sleep
❑ Early AM awakening
❑ Difficulty maintaining sleep
❑ Hypnogogic/Hypnapompic hallucinations
Risk Factors:
❑ Hypertension
❑ Stroke
❑ Myocardial Infarction
❑ CHF
Current Medications (please list or attach): ___________________________________________________________________________________
Allergies (please list) ________________________________________________________________________________________________________
Physician exam (please attach clinic note and patient demographics)
______ Height
______ Weight
______ BMI
______ Obesity
______ Epworth
Suspected Diagnoses (check at least one):
❑ Obstructive Sleep Apnea (327.23)
❑ Complex/Central Sleep Apnea (327.21)
❑ Narcolepsy (347)
❑ Parasomnia (please check)
❑ Limb movements (327.51)
❑ Sleepwalking (307.46)
❑ Seizure (345.10)
❑ Insomnia (780.52)
❑ Other (please specify): _____________________________________________________________________________________________________
ICD-CM Diagnosis Codes for each diagnosis: _______________________________________________________________________
Test(s) Requested:
Special requirements:
❑ Polysomnography (95810)
❑ Video
❑ Begin O
pre study
2
❑ C/Bi/ASV Titration (95811)
❑ Additional EEG
❑ If SAO
is less than 85%
2
❑ Split night (95811)
❑ May use O
up to 5 lpm to maintain greater than 90% saturation
2
❑ Home Sleep Test (95806)
❑ Three Night Premium Home Testing Service
❑ MWT (95805)
❑ MSLT (95805)
Follow-up Options: (A copy of all results will be sent to the referring physician)
❑ Perform the CPAP/Bi-Level titration if polysomnogram demonstrates sleep apnea
❑ Referring Doctor will counsel patient and order further studies or treatment as needed
❑ Consult the interpreting physician for patient’s management
❑ Sleep Center to arrange for CPAP/BiPAP therapy
Referring Physician Information
Physician Name (first & last): _______________________________________ NPI#: _______________________ GA License#: ____________________________
Physician Address: _________________________________________________ Phone#: __________________________ Fax #: ______________________________
I herby certify that the services in the above order form are medically necessary.
Physician Signature: _____________________________________________________________ Date: _____________________ Time: _____________________
FAX Orders to: 404.501.7088
Phone: 404.501.5927
SLEEP DISORDER CENTER
ORDER FORM
DMC FORM # PS-1058 (10/31/14)

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