SLEEP LAB REFERRAL FORM
FOR SLEEP LAB USE ONLY
(See sleep lab contact information on page 2)
TODAY’S DATE: PATIENT NAME: PHONE: SEX: DOB: EMMI:
ADDRESS: CITY: STATE:
ZIP:
INSURANCE (PRIMARY):
POLICY #: PRE-AUTH:
Sleep Specialist
DIAGNOSIS CODE: Date/Time
INDICATIONS for Sleep Apnea Testing
CONSULTS and TESTS
STOP-BANG assessment tool for sleep apnea
SLEEP CONSULTATION/MANAGEMENT
� Snoring, loud
� Tiredness/fatigue/daytime sleepiness
� Observed apnea
� Pressure: Hypertension
� Body mass index (BMI) greater than 35?
� Age older than 50 years?
� Neck circumference greater than 16 inches (if female) or 17 inches
(if male)?
� Gender = male?
� Sleep Consultation and Management: Sleep Specialist to
manage testing, treatment, and follow-up.
STOP-BANG Questionnaire adapted with permission from Dr. Frances Chung
and University Health Network, 2014.
Other associated symptoms and conditions
� Sensitive occupation:
� Chronic opioid use:
� Atrial fibrillation or other dysrhythmia:
� Cardiovascular disease:
� Neurological disease:
� Related airway anatomy findings:
� Metabolic syndrome OR � Type 2 Diabetes
� Chronic lung disease:
�Other: treatment and follow-up.) Select options(s) below:
� Diagnostic full-night polysomnography (No CPAP)
� Split-night polysomnography (Use of American Association of
Sleep Medicine (AASM) criteria recommended)
� Full night of CPAP (Patient must have documented diagnosis of
OSA by PSG; if no diagnostic PSG, consider repeat PSG, split-night, or
sleep consult)
Reason for full-night CPAP:
� Home sleep test (HST) (Requires consult with sleep specialist)
� Other:
URGENCY for CONSULT / TESTING
� Not urgent
� Urgent due to:
� Driving risk � Severe hypoxemia
� Other:
Nocturnal oximetry testing (Please attach if done)
Baseline O2 SAT: SLEEP TESTING ONLY (Referring physician will manage
� Job sensitive
SPECIAL NEEDS
�Falls risk:
Lowest O2 SAT: � Language barrier:
Desat index: Other symptoms and concerns (attach other sleep
questionnaires, if used, or additional clinical information)
REFERRING PHYSICIAN:
Signature:
*50261*
Order 50261
SLEEP LAB REFERRAL FORM
CPM031a - Page 1 of 2
©2010–2014 Intermountain Healthcare. All rights reserved.
Patient and Provider Publications. 801-442-2963
(See sleep specialist and sleep lab contact information on page 2.)
�Other: Note: Prescribe sleep aid prior to study and instruct patient to take to the
sleep lab. Most sleep labs do not have staff qualified to dispense medications.
Phone:
FAX:
Date:
Time:
SLEEP MEDICINE SPECIALISTS:
To find a sleep specialist, go to intermountainhealthcare.org/providers and scroll to “Sleep Medicine”
on the “Specialty” menu. You can narrow your search by Hospital Affiliation, City, ZIP, or County.
INTERMOUNTAIN SLEEP LAB CONTACT INFORMATION:
REGION
SLEEP LAB OR CENTER
REGION
SLEEP LAB OR CENTER
Idaho
Cassia Regional Medical Center
Mini-Cassia Sleep Lab
Summit
County
Park City Medical Center Sleep Lab
Wasatch
County
Heber Valley Medical Center Sleep Lab
1501 Hiland Avenue, Suite E, Burley, ID 83318
Phone: 208-677-6488 FAX: 208-677-6335
Northern
Utah
Bear River Valley Hospital Sleep Lab
905 North 1000 West, Tremonton, UT 84337
Phone: 435-207-4500 Contact: Mark Thompson
Logan Regional Hospital Sleep Center
500 East 1400 North, Logan, UT 84341
Phone: 435-716-5709 FAX: 435-716-2969
Utah
County
Salt Lake
County
Alta View Hospital Sleep Center
9660 South 1300 East, Sandy, UT 84094
Phone: 801-314-2400 FAX: 801-314-2385
Fork Hospital Sleep Center
*American
170 North 1100 East, American Fork, UT 84003
AASM
Phone: 801-855-4598 FAX: 801-442-0432
1034 North 500 West, Provo, UT 84604
Phone: 801-855-4598 FAX: 801-442-0432
Southern
Utah
* Dixie Regional Sleep Medicine CenterAASM
652 S. Medical Drive, Suite 310, St. George, UT 84790
Phone: 435-251-3940 FAX: 435-251-3941
Note: This lab does not accept direct sleep test referrals from
non-board-certified sleep doctors.
Avenues Sleep Disorders Center
440 D Street, Salt Lake City, UT 84143
Phone: 801-408-3617 FAX: 801-408-1516
1485 South Highway 40, Heber City, UT 84032
Phone: 435-657-4443 FAX: 435-657-4365
*Utah Valley Regional Sleep CenterAASM
McKay-Dee Hospital Sleep Center
4401 Harrison Boulevard, Ogden, UT 84403
Phone: 801-387-2700 FAX: 801-387-2709
750 Round Valley Drive Suite 101A, Park City, UT 84060
Phone: 435-657-4443 FAX: 435-657-4365
Rural Utah
Intermountain Medical Center Sleep Lab
(inpatient only)
5121 Cottonwood Street, Murray, UT 84107
Phone: 801-507-9582 FAX: 801-507-9598
Garfield Memorial Hospital Sleep Lab
200 North 400 East, Panguitch, UT 84759
Phone: 435-462-4190 FAX: 435-676-1541
Sanpete Valley Hospital Sleep Study Lab
1100 South Medical Drive, Mount Pleasant, UT 84647
Phone: 435-462-4601 FAX: 435-462-4627
* LDS Hospital Sleep Disorders CenterAASM
Sevier Valley Medical Center Sleep Lab
8th Avenue and C Street, Salt Lake City, UT 84143
Phone: 801-408-3617 FAX: 801-408-5110
1000 North Main, Richfield, UT 84701
Phone: 435-893-0252 FAX: 435-893-0258
Medical Center
* Primary Children’s
AASM
Sleep Center
100 Mario Capecchi Drive, Salt Lake City, UT 84113
Phone: 801-662-1780 FAX: 801-662-1785
Notes:
Riverton Sleep Lab
Sleep “Centers” (versus “Labs”) usually have onsite sleep
specialist consultation and follow-up.
3723 West 12600 South Suite 480, Riverton, UT 84065
Phone: 801-285-4870 FAX: 801-412-3160
* TOSH Sleep Disorders CenterAASM
5770 South 250 East Suite 340, Murray, UT 84107
Phone: 801-314-2400 FAX: 801-314-2385
*50261*
Order 50261
SLEEP LAB REFERRAL FORM
CPM031a - Page 2 of 2
(Please complete page 1 of this referral form and forward to one
of the sleep medicine specialist or sleep labs/centers above.)
* = Sleep Centers currently accredited by the American
Association of Sleep Medicine (AASM)