Home Sleep Study Order Form (Durden)

HOME SLEEP STUDY ORDER

(Dr. Durden)
PATIENT INFORMATION
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Sex*
Phone Number:*
E-mail
example@example.com
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company*
Insurance Policy #*
Please Upload Insurance Card Image if possible

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REFERRING PROVIDER INFORMATION
Provider Name*
Provider NPI Number
Office Phone*
Office Fax*
Provider Email*
Please provide an email if you wish to receive confirmation that this referral has been successfully submitted to Athens Pulmonary & Sleep Medicine.
PATIENT HEALTH INFORMATION

Symptoms/Indications for Testing
Please select ALL symptoms that apply:*

Previously Diagnosed: G47.33SnoringWitnessed ApneaExcessive Daytime SleepinessObesity (BMI>30)Awakens Gasping/ChokingMorning HeadachesHypertensionNon-Restorative SleepImpaired Cognition (Poor Memory & Concentration)
Please indicate the reason for the Home Sleep Study

Initial Evaluation of Suspected OSAOral Appliance Treatment - Final Titration EvaluationOral Appliance - Annual Follow-UpOther
In addition to G47.33 (Obstructive Sleep Apnea), please indicate any additional sleep related diagnosis codes that may apply
Other Diagnosis Codes
Please indicate if any of the Contraindications for home sleep testing apply.
Please select ALL that apply:*

NoneCOPDCongestive Heart Failure (CHF)Neuromuscular ImpairmentStroke HistorySignificant Cardiac DiseaseRestless Leg SyndromeOther Suspected Sleep DisorderOther
This referral cannot be processed until the patients most recent office note or H&P has been received by Athens Pulmonary & Sleep Medicine.

If you would like to upload the patients records, please use the link below.

If you prefer to fax the patient records, please fax to 706-549-5825.
Please Upload Office Notes and/or H&P

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TESTING / TREATMENT PLANS
This referral form constitutes an order to perform a diagnostic home sleep study.

After the home sleep study, please indicate below how you would like for us to handle the follow-up and treatment plan for this patient.
Please Choose Follow-up Option*
Ordering Provider Statement

I am requesting a diagnositc home sleep study for this patient. I certify that, to the best of my ability, I have accurately answered all questions on this referral form and submit this referral form as an executable order for a diagnostic home sleep study. I understand that this referral cannot be processed until the patient's most recent office note or H&P has been received by Athens Pulmonary & Sleep Medicine. Please follow the instructions indicated above to coordinate the follow-up and treatment plan for this patient.
Provider Signature*
Please type your name above as your electronic signautre.
DISCLAIMER: By typing your name above, you are signing this Order electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this sleep study order.
Should be Empty:

PATIENT INFORMATION

REFERRING PROVIDER INFORMATION

PATIENT HEALTH INFORMATION

TESTING / TREATMENT PLANS