New Home Sleep Study Request - Blackstone Medical Services

Patient Name*

Gender*

DOB*

Phone*

Alternate Phone

Height

Weight (lbs.)

BMI

Please enter a number from 0 to 99.

Neck Circumference (inches)

Please enter a number from 0 to 99.

Primary Insurance*

Specify Other*

ID Number*

Secondary Insurance

ID Number

Study Requested (CPT-4)

Diagnosis Code (ICD-10)

Chief Complaint (check all that apply)

Choking or gasping during sleep
Observed Apnea
Excessive daytime sleepiness
Snoring
Fatigue
Other

Chief Complaint (check all that apply)

Choking or gasping during sleep
Observed Apnea
Excessive daytime sleepiness
Fatigue
Snoring
Failed CPAP
Bruxism
Other

HST Purpose

Settings

1stNight 2nd Night

EPWORTH SLEEPINESS SCALE (For Insurance Purposes: assessment below must be completed prior to ordering a HST)
Please select the patient's likelihood to doze off for each of the scenarios below

Sitting and Reading

In a car stopped in traffic

Passenger in car under an hour

Sitting quietly after lunch without alcohol

Lying down to rest in the afternoon

Sitting inactive in a public place

Sitting and talking with someone

Watching tv

Attach File(s)

Attach authorization(s)

NPI

Pre-populated field

Office Contact

Pre-populated field

Provider Name

Pre-populated field

User Email

User Phone

Address

Address2

City

State

Zipcode

ProvParameter

Practice Type

Fax Number

New Sleep Study Request

New Sleep Study Request

Create a New Home Sleep Study Request