Physician referral Programme
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SLEEP LAB PATIENT REFERRAL FORM Patient’s Name: ____________________________________________ DOB: ________________ Last Office Visit Date:-______________________ Pt Ht________Inches/Cm, Pt Weight_______lb/Kg Referring Diagnosis: Heavy snoring Clinical Indications for referral: 327.23 Witnessed apnea Unexplained Drowsiness 780.54 Obesity Sleep Apnea 327. 23 Frequent napping Restless Leg Syndrome 333.99 Epworth score Insomnia 307.42 Morning Headaches Hypersomnia with sleep apnea 780.53 Enlarged Tonsils Narcolepsy 347.00 Excessive Daytime Sleepiness Other Reasons______________________ Evaluate for Narcolepsy Special Needs: __ Wheelchair __ Walker __ Oxygen __ Other___________________ Type of Study Requesting: Please check one 95810-PSG in sleep lab (Sleep staging with 4 or more additional parameters of sleep, attended by a technologist.) *A PSG is the gold standard for diagnosing every type of sleep disorder. 95811-Split sleep study in sleep lab (PSG and CPAP titration, ONLY if protocols are met that night.) 95811-CPAP sleep study in sleep lab (Sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or Bilevel ventilation, attended by a technologist) *Need copy of PSG or home study. 95805-Multiple Sleep Latency-MSLT (Maintenance of wakefulness testing, recording, analysis, and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness.) 95806-Home sleep study PSG (Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, unattended by a technologist; to diagnose sleep apnea only.) I certify that I am the treating physician for the above patient. I certify that the referring Diagnosis and the indications are true, accurate and complete, to the best of my knowledge. I certify that the above test ordered is medically necessary in the treatment of this patient. Any statement here has been reviewed and signed by me. PHYSICIAN’S SIGNATURE________________________________DATE________________________ NPI#____________________________________ PA-LIC # _____________________________________ 1718 Welsh Road, Second Floor Philadelphia, PA 19115-4213 215-676-2334(P)- 215-676-2366(F) Patient’s Name: ____________________________________________ DOB: ________________ Medical History Yes Head Stroke Head Trauma Loss of consciousness Seizure Migraines Dizziness Hearing impairment Visual impairment ___________________ Heart High blood pressure Heart attack Atrial Fibrillation Murmur Congestive heart failure Coronary disease Stents Angioplasty Pacemaker High Cholesterol Anemia ___________________ Lungs Emphysema (COPD) Bronchitis Asthma Tuberculosis (TB) ___________________ Endocrine Diabetes Hypothyroidism Hyperthyroidism _____________________ Cancer Cancer No Comment __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ Yes Gastrointestinal Reflux Ulcer Diverticulosis _______________ Urinary Frequent urinary infections Kidney stones Enlarged prostate ________________ Musculoskeletal Osteoarthritis Rheumatoid arthritis Degenerative joint Fractures ___________________ Surgeries Cataracts L R Tonsillectomy Gall bladder Hernia – Inguinal Hysterectomy Appendectomy ________________ Sleep Insomnia Excessive day time sleepiness Apnea Nightmares Nocturnal seizures Night sweats Sleep walking Other: Addictions No Comment __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ PHYSICIAN’S SIGNATURE____________________________________DATE________________________ 1718 Welsh Road, Second Floor Philadelphia, PA 19115-4213 215-676-2334(P)- 215-676-2366(F) We accept direct referral from the following Insurance Carriers. Poly-Tech Sleep Services NPI#-1518197847 TAX ID #- 26-3823390 Our list is updated as the credentialing process is completed with other carriers. Please call 215-676-2334 or 215-858-4700, for any insurance carrier not on this list. Insurer American Postal Workers Union Beech Street Blue Cross Blue Shield - applies to all BCBS members with traditional or PPO coverage (suitcase on their member card) CIGNA-PA/DE GREATWEST-One Health Plan of PA Keystone Health Plan East Keystone Mercy Medicare Multiplan, Inc Medicaid/ Medical Assistance – PA Prudential Healthcare System Teamster Health & Welfare Fund Personal Choice Group # 6060162 26-3823390 2511903 6060162 26-3823390 Scheduling for month of March 2011. Scheduling for month of March 2011. 188416 26-3823390 102514847-0001 9950537 2511903 As we promised, we will do all the pre-certification with the insurance carrier as long as you send us the following documents to 215-676-2366, If the patients insurance carrier required to have a referral, please attach that along with the fax. 1. Recent Office Visit sheet including History & Physical or the attached H&P. 2. Attached “Sleep Study Requisition form” with Physician Signature. 3. Copy of the patient’s Insurance Identification Card (Front & Back) 4. Patient Demographic Informations. 1718 Welsh Road, Second Floor Philadelphia, PA 19115-4213 215-676-2334(P)- 215-676-2366(F)
