Referral Form
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1Let us know when patient is scheduled:
YES
NO
Date Scheduled: _________________
Scheduled By: _________________
Referral Form
Please fax patient demographics, referral form, H&P, & a copy of patients’ insurance cards to
(785) 404-3333
Patient Name: ____________________________________________ DOB: ___________________
Telephone: (Home) __________________________ (Daytime) ______________________________
Primary Insurance: _____________________________ ID # ________________________________
Referring Physician: ___________________________ NPI# ________________________________
Patient Epworth Sleepiness Scale (ESS) score _______
Indication for Sleep Evaluation: (Please Check)
Organic Sleep Apnea, Unspecified (327.20)/**Applicable ICD-
□
Insomnia with Sleep Apnea, Unspecified
□
10 (G47.30)
(780.51)/**Applicable ICD-10 (G47.30)
S
Periodic Limb Movement Disorder (327.51)/Direct ICD-10
□
Hypersomnia (780.54)/**Applicable ICD-10 (G47.10)
□
(G47.61)
except BCBS
Unspecified Sleep Apnea (780.57)/**Applicable ICD-10
□
Obstructive Sleep Apnea (327.23) Direct ICD-10 (G47.33)
□
(G47.30)
Other ____________________________
□
*Snoring & fatigue cannot be the sole indications for doing a sleep study. They are non-covered diagnoses.*
**
Codes may require clinical interpretation in order to determine the most appropriate conversion code(s) for your
specific coding situation.
Study Type: (Please Check)
95810 1
st
Night Test: All Night Polysomnography
□
95811 2
nd
Night Test: All Night CPAP Titration
□
95811 Split Night PSG/CPAP Titration (Will initiate CPAP if criteria met)
□
95810 PSG (Diagnostic) study followed by 95805 MSLT (Multiple Sleep Latency Test)
□
95805 MWT (Maintenance of Wakefulness Test)
□
95806 Home Sleep Study
□
TREATMENT AND CONSULTATIONS:
____ Dr. Kent Berquist Consultation: After the sleep study, final results will be sent to Dr. Berquist for patient
consultation, treatment and follow-up
____Patient will be followed up by ordering physician.
Special Instructions: (Please indicate if the patient will need any type of assistance, if the patient is on oxygen, uses a
wheelchair, walker, etc.)
__________________________________________________________________________
__________________________________________
_________________________
Physician Signature
Date
1007 Albert Ave ▪ Salina, KS 67401 ▪ (785) 785-6900
FAX (785) 404-3333
Revised date: June 2015
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