Sleep Center Referral - Sleep Wellness Center
|Patient Name: | Female Male |DOB: |
|Address: |City: |St: |Zip: |
|SSN: |Home Phone: |Cell Phone: |
|Emergency Contact Name: |Phone: |Relationship: |
|Indications: | Obstructive Sleep Apnea (OSA) (G47.33) | Periodic Leg Movement Disorder (G47.61) |
| | Narcolepsy (G47.41) | Hypersomnia, Unspecified (G47.10) |
| | Other Sleep Disturbances (G47.8) | Other: |
|Primary Insurance: |Phone: |
|Policy ID#: |Group #: |Insured Relationship: |
|Subscriber/Insured Name: |DOB: |Insured SSN: |
|Secondary Insurance: |Phone: |
|Policy ID#: |Group #: |Insured Relationship: |
|Subscriber/Insured Name: |DOB: |Insured SSN: |
|Procedure Ordered: | Full Diagnostic Polysomnography |
| | Full Polysomnography Split Night with CPAP/BIPAP if indicated |
| | Full Polysomnography for CPAP/BIPAP Titration |
| | Sleeping Aid if indicated (Patient should bring sleep aid to the appointment, or the medication should be available at the facility to be |
| |administered by the nursing supervisor) |
| | Home Sleep Study (unattended) |
| | Other: |
|If MSLT is indicated check here: | Multiple Sleep Latency Test |
|Is patient currently on Oxygen? | yes no |If yes, O2 LPM = |
|Special Instructions: | |
|Referring Physician: |Phone: |
|Address: |Fax: |
|City: |St: |Zip: |
|Physician Signature & Date: |( |Date: ( |
| NOTE: Please Fax a Copy of the Sleep Questionnaire & Chart Notes with this form |
|Please Fax Signed & Dated form to: Sleep Wellness Center – Winmar Diagnostics: 701-239-4792 |
2700 12th Avenue South, Suite B ( Fargo, ND 58103-8723 ( 701.235.7424 ( Toll Free: 800.962.8145 ( Fax: 701.239.4792
( info@
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