PAYSON SLEEP SERVICES, INC. 404 W. Main Street, Suite A, Payson, AZ 85541
Independent Diagnostic Testing Facility Phone (928) 474-5234 / Toll-free 1-888-720-5234
Fax (928) 474-5235 / Toll-free 1-888-304-5235
SLEEP STUDY REFERRAL
Please include sleep assessment or Dr’s notes for medical necessity, any previous studies, & insurance info.
Patient Name: ______M / F DOB:______Phone:______
Alternate Phone:______Insurance(s): ______
Referring Provider (print):______Office Phone:______
Preliminary Diagnosis:□ Suspected Sleep Apnea
□ Abnormal Nocturnal Oximetry
□ Suspected Narcolepsy / □ Known Sleep Apnea (by prior PSG)-----On PAP? _____cm
□ Suspected Parasomnia(s):______
□ Other:______
Type of Polysomnogram Ordered: (All PSGs monitor a minimum of 16 channels and are attended by a technologist.)
□ Diagnostic PSG (CPT Code 95810
This is an all-night diagnostic study only. CPAP will not be applied during the study regardless of results.
□ Split-Night PSG
o Standard Protocol: Apply CPAP after 1 - 3 hours of sleep time if/when AHI reaches 15 /hr
(Must meet above criteria with ample time to titrate CPAP ( 3 hours); otherwise 2nd night for CPAP Titration will be scheduled.)
o Other Protocol (Specify):______
□ PAP Titration PSG (CPT Code 95811)
This is appropriate for patients who have had an abnormal PSG within the last year that demonstrates obstructive sleep apnea, or any other condition for which CPAP may be indicated. Also appropriate for patients who have already been on PAP therapy, but may be having a recurrence of symptoms and/or difficulty tolerating the device.
AutoSV Titration: Appropriate for patients who have failed CPAP, BiPAP, and BiPAP-ST therapy modes.
□ (MSLT) Multiple Sleep Latency Test (CPT Code 95805)
Indicated for suspected Narcolepsy, or to document degree of daytime sleepiness.
□ (MWT) Maintenance of Wakefulness Test (CPT Code 95805)
Quantifies daytime alertness; may be used to evaluate effectiveness of various treatments on excessively sleepy patients.
Provider Signature: ______Date: ______