MLA HASS LUNG. SLEEP CENTER, Leominster Campus 100 Erdman Way, Leomjnster, MA Phone: Fax:
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1 MLA HASS LUNG SLEEP CENTER, Leominster Campus 100 Erdman Way, Leomjnster, MA Phone: Fax: MEICAL IRECTOR: Payam Aghassi, M, FCCP Thank you for your sleep study order! Attached please find our order form for sleep studies and consults. Please insure that these forms are completely filled out. We need the referral form signed, dated along with your printed name. Unless you are requesting a consult with MLA, we also require that a specific sleep study is selected. We will have to fax back incomplete orders Thank you, Scheduling and Administrative Staff Mass Lung Allergy Sleep Centers
2 LEOMINSTER SLEEP CENTER 100 Erdman Way Ste. 25 MASS Phone: Fax: MLA " WORCESTER SLEEP CENTER LUNG 85 Prescott St Ste. 302 Phone: Fax: A. PATIENT INFORMATION Patient Name: Address: City: SSN: OB: Apt: Sex:. State: Zip Code: Phone (Home): Work: Cell:. . Insurance Co: Secondary Insurance:. Group No.: Policy No.:: Policy: Group No: INITIAL CONSULT WITH SLEEP SPECIALIST AN SUBSEQUENT CLINICAL MANAGEMENT: Refer for initial consult to MLA Sleep Specialist for possible sleep disorder to include necessary diagnostic sleep studies and subsequent therapy including positive airway pressure (PAP) and clinical management if indicated. Skip to section OR: v11mca1 follow-up preference: LEOM:0 Payam Aghassl, M O Inna Kets/er, MO Joseph Wa/ek, M Oda/ys Croteau, M WORC: 0 Mustafa Albakour, M 0 Philip Burl<e, M O Steven avis, M O Stacia Sailer, M C. IRECT REFERRAL FOR SLEEP TESTING: All sections required. Ordering provider Is responsible for follow- up and treatment unless requested otherwise. ****PLEASE NOTE PRIOR AUTHORIZATIONS WILL BE OBTAINE THROUGH MLA SLEEP CENTER- However your last office note and MLA Clinical ata form Is r!qulr!s! 1. IAGNOSIS: Please check Primary and all Co-Morbid iagnosis that apply to this referral G47.33 Obstructive sleep apnea (adult/pediatric) G47.31 Complex Sleep Apnea G47.36 Sleep Related Hyperventilation/Hypoxemia G47.30 Unspecified Sleep Apnea G47.10 Hypersomnia, unspecified G47.9 Sleep disturbance, unspecified G Nacolepsy G47.61 Periodic Limb Movement isorder G47.69 Sleep Related Movement isorder G47.50 Parasomnia, unspecified G47.52 REM Sleep Behavior isorder G Sleep Related Seizure isorder G47.8 ysfunctions associated with Sleep Stages or Arousal from Sleep 0 ~47 ~1 r.fmtr::il C::l,:u:,n.6.nn"'"' 2. EPWORTH: HEIGHT: WEIGHT: BMI: FeV1/FVC: FeV1: 3. SLEEP TEST ORERE: O HST- Unattended OSA Recording 95806/ G0399 ASV Titration POL YSOMNOGRAM ONL y (Left Ventricular Ejection Fraction: ) TcC02 Monitoring PSG if not approved HST pennissible 95810/95086 G0399 Medicare Oxygen Titration on PAP (Otherwise Physician agrees to peer to peer with this order) PSG/MUL TIPLE SLEEP LATENCY TEST (MSL n SPLIT NIGHT STUY PSG/MAINTENANCE OF WAKEFULNESS TEST CPAP TITRATION ONL y Special Requests: TcC02 ETC02(dx only) ate/location of 0 BiLevel TITRATION ONLY EXTENE EEG {Phase previous sleep study elay: Late Sleeper) Interpreter preference: LEOM : 0Payam Aghassi, M Inna Keisler, MO Joseph Wa/ek. M Oda/ys Croteau, M WORC0Mustafa Albakour, Ml:(]Phllip Burl<e, M OSteven avis, M [}Stacia Saller, M. REFERRING PHYSICIAN/RN SIGNATURE PHYSICIAN SIGNATURE: ate: NURSE PRACTITIONER/RN SIGNATURE: ate: Printed Name: Phone: Fax: Address: Office Contact:
3 Epworth Sleepiness Scale (REQUIRE FOR ALL PRE-AUTHORIZATIONS) The Epworth Sleepiness Scale is used to determine the level of daytime sleepiness. Use the following scale to choose the most appropriate number for each situation: O = would never doze or sleep. 1 = slight chance of dozing or sleeping 2 = moderate chance of dozing or sleeping 3 = high chance of dozing or sleeping Sitting and reading Watching TV Sitting inactive in a public place Being a passenger in a motor vehicle for an hour or more Lying down in the afternoon Sitting and talking to someone Sitting quietly after lunch (no alcohol) Stopped for a few minutes in traffic while driving Total score (add the scores up) (This is your Epworth score)
4 PATIENT CLINICAL ATA-REQUIRE FOR PRE-AUTHORIZATION (NOT REQUIRE IF REFERRING PATIENT FOR A SLEEP CONSULTATION) COMPLETE ALL SECTIONS CHECK ALL THAT APPLY PATIENT NAME: OB: Height: Weight: BMI: Shift Worker: Symptoms interfere with ALs:_ Cognitive impairment (inability to follow simple instructions will interfere with Home Sleep Study Instructions): A. CURRENT REPORTE PATIENT COMPLAINTS: _ isruptive snoring Excessive aytime Sleepiness _ isturbed or Restless sleep _ Non restorative sleep Unable to tolerate current PAP pressure Fatigue _Irritability/moodiness Patient awakens gasping or breath Inability to fall asleep Complaint duration: < one month _ >one month >three months >six months B. SIGNS AN SYMPTOMS: Witnessed apnea events, choking or gasping. Frequent unexplained arousals _Nonambulatory individual Nocturia Morning Headaches Restless or jerking legs Suspected cataplexy Frequent prolonged daily naps Symptom duration: < one month_ >one month >three months >six months Assessment of hypersomnolence: Impairment of Job Performance Impairment of safety Impairment of driving Is the FEVl/FVC </= to 0. 7? Yes NO FEVl <80% of predicted:. C. CO-MORBI CONITIONS (Recent office note is required): Unexplained pulmonary hypertension Uncontrolled COP /Lung isease Uncontrolled CHF (Class Ill or IV) _ Uncontrolled significant, persistent cardiac arrhythmia _ Suspected Nocturnal Seizures_ Neuromuscular weakness and impaired respiratory function iabetes Nocturnal esaturation -- Co Morbid uration: < one month >one month >three months >six months
5 . NON-OSA SUSPECTE SLEEP ISORER Complex Sleep isordered Breathing Suspected REM behavior disorder Suspected Narcolepsy Periodic Leg Movements (Periodic Limb Movement isorder) Restless Leg Syndrome Suspected Parasomnia Central Sleep Apnea Circadian Rhythm isorder Idiopathic Hypersomnia E. REPEAT SLEEP STUY IS THIS A REPEAT SLEEP STUY: YES NO IF YES COMPLETE THE FOLLOWING: Was a previous Sleep Study completed at MLA Sleep Center? YES NO IF the Sleep Study was completed at another facility are you able to fax us the Technical Report and Interpretation? IF NO Name of Facility: IF PATIENT IS ON PAP THERAPY ARE YOU ABLE TO FAX THE MOST RECENT COMPLIANCE REPORT THAT HAS AT LEAST 2 MONTHS OF RECORE ATA? YES NO -- tf NO CAN THE PATIENT REPORT: PAP used > 2 months PAP Therapy> 4 hours/night for at least 70% of nights IF PATIENT CANNOT REPORT ABOVE INFORMATION, PLEASE STATE WHY NOT COMPLIANT WITH PAP THERAPY: F. EPWORTH SLEEPINEES SCALE This is required for all prequthorizations. Please see the scoring sheet that follows
Sleep Center. Have you had a previous sleep study? Yes No If so, when and where? Name of facility Address
Patient Label For office use only Appt date: Clinician: Sleep Center Main Campus Highlands Ranch Location 1400 Jackson Street 8671 S. Quebec St., Ste 120 Denver, CO 80206 Highlands Ranch, CO 80130 Leading
Emergency Contact Information Name: Phone: Address: Employer Information Employer Name: Address/Street: City: Zip: Phone: Fax:
SUNSET SLEEP LABS PATIENT INFORMATION FORM Patient Information Name: Sex: M F Date of Birth: Address/Street: City: Zip: Phone: Alt Phone: Parent/Guardian: Phone: Social Security Number: Drivers License:
PORTABLE OR HOME SLEEP STUDIES FOR ADULT PATIENTS:
Sleep Studies: Attended Polysomnography and Portable Polysomnography Tests, Multiple Sleep Latency Testing and Maintenance of Wakefulness Testing MP9132 Covered Service: Prior Authorization Required: Additional
Sleep Studies: Attended Polysomnography and Portable Polysomnography Tests, Multiple Sleep Latency Testing and Maintenance of Wakefulness Testing
Portable Polysomnography Tests, Multiple Sleep Latency Testing and Maintenance of Wakefulness Testing MP9132 Covered Service: Yes when meets criteria below Prior Authorization Required: Yes as indicated
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Name: Sex: Age: Date: Date of Birth Height Weight Neck size Referring Physician: Primary Care MD: Main Sleep Complaint(s) trouble falling asleep trouble remaining asleep excessive sleepiness during the
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Polysomnography (PSG) (Sleep Studies), Sleep Center
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