Sleep Diagnostics Of Fremont printable pdf download

SLEEP DIAGNOSTICS OF FREMONT

556 Mowry Avenue, Suite 102, Fremont, CA 94536

Main: (510) 742-5432

Fax: (510) 742-8767

SLEEP EVALUATION REQUEST

Patient Name: FIRST___________________________MI_______LAST_______________________________________

Date of Birth: _______/_______/________

Phone: (H)________________(W)_______________(C)_____________

{CHECK ALL ORDERS THAT APPLY}

_____ Consult/Management - Consult with a Board Certified Sleep Specialist to evaluate and manage sleep issues prior to

and/or post test(s).

_____ Comprehensive Polysomnography – Gold Standard Diagnostic sleep study and if positive for apnea/hypopnea,

followed by CPAP titration study. If the patient has enough respiratory events in first part of study, they may qualify for a

Split Night study

_____ Diagnostic Polysomnography only

[Do not titrate CPAP.]

_____ CPAP/Bi-Level PAP/ASV Titration Polysomnogram

[Study begins on CPAP (unless otherwise indicated), if failure

try BiPAP or ASV.]

_____ Multiple Sleep Latency Test (MSLT)/Maintenance of Wakefulness Test (MWT)

[Daytime Nap Studies]

_____ AMA Impairment Study to Include PSG with MSLT. [Study includes AMA Impairment Report using 5

Edition AMA

Guides.]

_____ Home Sleep Test

Type II diagnostic home sleep study to evaluate for sleep disordered breathing

PLEASE FAX THIS FORM TO (510) 742-8767 WITH THE FOLLOWING INFORMATION:

1. Copy of insurance card

2. Patient demographic information

3. Clinical notes related to sleep issues

PRELIMINARY DIAGNOSIS CODES

_____Sleep Apnea/Sleep Related Breathing Disorder, Unspecified (ICD-9-CM 327.20)

_____Obstructive Sleep Apnea (ICD-9-CM 327.23)

Other:__________________________________

Clinical presentation/symptoms/existing illnesses (notation not needed if clinical notes faxed):

___________________________________________________________________________________________________

______ Patient to self-administer own medicine OR offer patient Lunesta 3mg (or Lunesta 2mg if age > 65) to self-administer if

unable to initiate sleep within 45 min after lights out

_____Oxygen to be titrated as needed

Other special instructions regarding study:___________________________________________________________________

ORDERING PHYSICIAN INFORMATION

Physician Name:___________________________________

Office Contact Person:______________________________

Phone:___________________________________________

Fax:_____________________________________________

PHYSICIAN SIGNATURE: ______________________________________________________________________________

I certify that to the best of my knowledge, this test and any interpretation is medically necessary in order to provide information which will assist

in the proper diagnosis and/or treatment for the above named patient.

Sleep Diagnostics Of Fremont

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