Sleep Center Referral Form for McLaren Greater Lansing

Sleep Center Referral Form

Note: Fields marked with an * indicates required field

Patient Name: *

Street Address: *

City: *

Zip Code: *

Home Phone (With Area Code): *

Work Phone:

Social Security Number: *

Date of Birth: *

Complaints/ Symptoms Noted:

Please mark if the patient has any of the following:

Note: Add the following comment to the form: If any box is checked in this section the patient most likely will NOT qualify for an OCST (at home study) due to their comorbidities and complexity of their condition. OCST may not be reliable in these cases. An in-lab study is recommended. Please verify with the patient's insurance company.

Type of Study: *

95810 - Baseline/Diagnostic In-lab Sleep Study

95811 - Titration In-Lab Study

95805 - Multiple Sleep Latency Test (MSLT) to diagnose Narcolepsy or assess unexplained sleepiness

95805 - Maintenance of Wakefulness Test (MWT) to assess daytime alertness

95806 - Out of Center Sleep Testing (OCST) performed at home

94762 - Overnight Home Oximetry at home

94660-PAP Desensitization or Assistance Session (for person with claustrophobia, anxiety or having difficulty with their PAP equipment

94660 -AutoPAP trial (at home, if able to complete OCST, and required by insurance in lieu of in-lab titration.)

Office Contact: *

Comments:

Ordering Physician: *

Physician Phone Number: *

Physician Electronic Signature of NPI Number: *

Copy to Physician: *

Requestor Name:

Requestor Email Address: *

Insurance:

Insurance carrier: *

Pre-authorization number:

If the patient *

Pre-Authorized number is needed

Patients insurance does not require a pre-authorization

Unable to obtain pre-authorization at this time. Will forward when we receive.

Captcha*