Good Night Sleep Wellness Center

Patient Information

First Name:

Last Name:

Date of Birth:

Phone (Home):

Phone (Work or Cell):

Physician Information

First Name:

Last Name:

Phone:

Fax:

NPI:

Consultation Options

Sleep Medicine Specialist Consultation

Sleep Medicine Specialist Follow-Up

No Consultation

Sleep Testing Options

Diagnostic Sleep Study CPT: 95810
(Test to rule out Sleep Apnea or other sleep disorder.)

Split Night Study CPT: 95811
(Diagnostic Sleep Study with CPAP titration if OSA is detected.)

CPAP Titration CPT: 95811
(Titration of CPAP to alleviate OSA.)

Multiple Sleep Latency Test CPT: 95810+95805
(Study to measure daytime sleepiness or detect narcolepsy.)

Maintenance of Wakefulness Test (MWT) CPT: 95810+95805
(Test to measure ability to stay awake.)

Special Instructions / Needs

O₂ -> lpm	Wheelchair
Bedside Commode	Urinal
Other (Specify Below)

Indication(s) for Referral (Check All that Apply)

Snoring (786.09)History of Stroke (437.9)
Daytime Sleepiness (780.54)Ischemic Heart Disease (414.9)
Witnessed Apnea (780.53)Insomnia (307.42)
Obesity (278.01)Parasomnia (327.40)
Hypertension (401.9)Restless Leg Syndrome (780.10)
Sleep Disturbance (780.50)Cataplexy
Fatigue (780.79)Hypnagogic Hallucinations
Depression (296.2)Other (Specify Below)

To ensure proper diagnosis and insurance coverage for this patient, please fax the following information to Good Night Sleep Wellness Center at (623) 792-5428

Copy of insurance card, front and back. (Please enlarge card).
Copy of patient demographics/contact information.
Any medical history related to the ordering of this sleep study.

Electronic Signature - Please electronically sign this form by typing your full first and last name below and clicking the 'Submit' button.