Sleep Study/Evaluation Referral Form

Accredited by the American Academy of Sleep Medicine

PLEASE INCLUDE CHART NOTES, MEDICATION LIST AND FRONT/BACK OF RECENT INSURANCE CARDS

Patient Name

Date of Birth

Please upload a copy of your current insurance cards, front and back are required.

Add file

Please upload a file

Home/Work Phone

Cell Phone

Primary Insurance

Primary Insurance ID

Secondary Insurance

Secondary Insurance ID

MEDICAL HISTORY (a history and physical exam is required)

Suspected Diagnosis:

Signs/Symptoms:

Sleep apnea Restless leg Syndrome Insomnia Narcolepsy

Snoring Witnessed apnea Obesity Daytime Sleepiness

Past Medical History:

Special Needs:

CAD HTN Stroke COPD

Nocturnal O2: L/min Wheelchair

PATIENT IS BEING REFERRED FOR (check only ONE):

Consultation and Management. Visit with a sleep specialist to evaluate and treat patient.

Or, a Direct Sleep Study (Listed below) – In which the Ordering provider is responsible for discussing test results with patient and initiating treatment, if indicated

Diagnostic Polysomnogram: Full night sleep study

Split Night Polysomnogram: Full sleep study. First part diagnostic and second part CPAP titration, if criteria is met.

Home Sleep Study: Patient is able to cooperate in the self-application and removal of home testing equipment.

PAP or BiPAP Titration: Full night sleep study for patients with documented sleep apnea.

*Please include current CPAP/BIPAP pressures and a reason for re-titration (e.g fatigue, weight gain, etc).

Matrix Titration: This titration uses a Matrx tray to determine whether a patient will be a responder to oral appliance therapy. Patient must bring the Matrx tray to the study as created by his/her dentist.

mm is the Comfortable/Regular bite

mm is the Maximum Protrusion

Diagnostic Study w/Oral Appliance: Providing objective information regarding how well an appliance is maintaining a patient’s airway.

ORDERING CLINICIAN INFORMATION

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Name

Signature

Address

Phone

Fax

Please note that for pediatric referrals we ask that you use the Pediatric Patient Referral Form. This can be obtained at pacificsleepprogram.com/providers or by contacting our office at 503-228-4414

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