Sleep Disorders Center Referral Form
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1Physician Connection Line
Phone: 1-866-DHMC DOC
(866) 346-2362
Referral Form
Fax form to:
Fax: (603) 676-4080
Sleep Disorders Center
Please indicate preference:
DHMC Referral
CVH Referral
Today’s date: ______________________
Patient name: ___________________________________________________ DOB: _______________________ SSN: ______________________
Home phone: ____________________________ Work phone: ___________________________ Cell phone: _____________________________
Mailing address: ____________________________________________________________________________________________________________
Parent/guardian: ___________________________________________________________________________________________________________
Insurance provider: ___________________________________________________________ Insurance policy #: ____________________________
Insurance phone number: __________________________________________ Insurance referral submission date: ___________________________
Subscriber’s name: ___________________________________________________________ Subscriber’s SSN: _____________________________
Referring provider: ______________________________________________ Contact person: ___________________________________________
Office phone: ___________________________________________________ Office fax: _______________________________________________
Primary care physician (if different from above): ________________________________________________________________________________
Contact person: _____________________________________________________________________________________________________________
Primary care physician phone: _____________________________________ Primary care physician fax: _________________________________
Sleep Disorders Center Referral Information
Reason for referral: ________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
Prior PSG:
No
Yes
When ________________ (please forward copy)
Height: _____________ Weight: _____________
Signs and symptoms: (check all that apply)
Observed apnea
Daytime sleepiness
Snoring
CHF
Periodic limb movements
Insomnia
Restless legs
Morning headaches
COPD
High BP
Parasomnia (e.g. sleepwalking)
Medical conditions:
Using Oxygen:
No
Yes
_____________ lpm
Nighttime
Continuous
Tracheotomy
Physically disabled:
No
Yes (explain)
___________________________________________________________________________
Developmentally disabled:
No
Yes (explain)
___________________________________________________________________________
Other medical conditions: ____________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
Sleep Disorders Center Office Use Only
Patient MR#: ________________________
PSG consult
Insomnia consult
Other: ________________________________________
Date referral received: ___________________ Date sent for verification: ___________________ Date verification received: ___________________
Referral needed:
Consult
No
Yes
Date sent: ____________________________________________________________
PSG
No
Yes
Date sent: ____________________________________________________________
Authorization needed:
Consult
No
Yes
Authorization #: ______________________________________________________
PSG
No
Yes
Authorization #: ______________________________________________________
Contact #1: _____________
Contact #2: _____________
Letter sent: _____________ Consult appointment date: ________________________
One Medical Center Drive | Lebanon, NH 03756 | Tel: (603) 650-5000 |
Rev. 11
-16-09
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