Sleep Study Evaluation Form - Shady Grove Adventist Hospital Page 2
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1
2Order for Sleep Diagnosis and Treatment
Patient Information:
Patient Name: ____________________________________________________ DOB: _________________________
Address: _________________________________________________________________________________________
Home Phone: ( ______ ) - ________ - ________________ Work Phone: ( ______ ) - _______ - ________________
Primary Insurance: _______________________________________________________________________________
Secondary Insurance: _____________________________________________________________________________
Physician Information:
Ordering Physician: _______________________ Primary Care Physician: _______________________
Phone: ( ______ ) ________ - ________________
Phone: ( ______ ) _______ - ________________
Fax: ( ______ ) ________ - ________________
Fax: ( ______ ) _______ - ________________
Diagnosis: _______________________________________________________________________________________
Orders:
COMPLETE COORDINATION OF CARE
: includes initial consultation, orders for sleep tests, evaluation of results,
patient follow-up and RX or referral for any treatment, including CPAP, medication, dental appliance, surgery, etc.
Post-Sleep Study Coordination of Care:
covers consultation after abnormal sleep study, including evaluation of sleep
study results, patient follow and RX or referral for any treatment, including CPAP, medication, dental appliance, surgery, etc.
Polysomnogram (PSG):
this overnight stay procedure will record three channels of EEG, two channels of eye movement,
one channel of chin EMG, nasal pressure transducer for airflow, tracheal microphone, chest expansion, diaphragmatic
excursion, EKG, leg EMG, body position and SAO2. This is the standard test for sleep apnea, snoring, restless legs syndrome
or narcolepsy.
:
Split-Night Polysomnogram
this is a regular PSG for approximately two hours, followed by CPAP titration if the apnea
hypopnea index is above 20/hour, or if desaturations are consistently below 85%. Original Split-Night order will qualify
patient for PSG as well as CPAP Titration Study if patient does not qualify for CPAP initiation in initial study. This is
indicated for patients with high probability of sleep apnea.
:
CPAP Titration
full night PSG with CPAP titration. This test is indicated for patients with documented sleep apnea.
CPAP Set-Up:
includes lifetime (99) RX for machine, mask, cushion, headgear, tubing, filter, heated humidifier and
patient care instructions with 1 week, 3 month and a 6 month follow-up.
Multiple Sleep Latency Test (MSLT):
attended daytime naps to investigate daytime sleepiness. A PSG is typically
performed the prior night to detect disorders of sleep and to insure adequate sleep time before testing for sleepiness.
Special Requests: _________________________________________________________________________________
All individual studies will be a full night study including three channels of EEG, two channels of eye movement, one channel of chin EMG, nasal
pressure transducer for airflow, tracheal microphone, chest expansion, diaphragmatic excursion, EKG, leg EMG, body position and SAO2.
Physician Preference:
onrad Bakker, MD.
Marc Raphaelson, MD.
James Yan, MD.
(please circle) K
All reading physicians are board certified in sleep medicine. Orders without a designated physician default to Konrad Bakker, MD.
The above referred patient has an absolute medical necessity for the item(s) listed above, based on the above preliminary diagnosis. I certify that the
above prescribed item(s) is/are medically indicated and, in my opinion, reasonable and necessary with reference to the standards of medical practice
and treatment of this patient’s condition.
Ordering Physician’s Signature: ___________________________________
Date: _____________________
Fax completed form to: (301) 251-1707
~ (301) 294.5580
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