New Sleep Study Request New Sleep Study Request Create a New Home Sleep Study Request Patient Name* Gender*MaleFemaleDOB* Date Format: MM slash DD slash YYYY Phone*Alternate PhoneHeightWeight (lbs.)BMIPlease enter a number from 0 to 99.Neck Circumference (inches)Please enter a number from 0 to 99.Primary Insurance*please select(self pay)AetnaAssurantAvmedBCBS (Medicare)BCBS (Non-Medicare)CareplusChampvaCignaFreedomGEHAGHIGolden RuleGreatwestHumanaMedicareMeritainMultiplanOptimumPHCSSimplyTricareUHCUHC MCR AARPUltimateWellcareOtherSpecify Other*ID Number*Secondary InsuranceID NumberStudy Requested (CPT-4)Not Specified95806 Home Sleep StudyG0399 Home Sleep StudyDiagnosis Code (ICD-10)Not SpecifiedG47.33 Obstructive Sleep ApneaG47.30 Sleep Apnea, UnspecifiedG47.39 Other Sleep ApneaDiagnosis Code (ICD-10)Not SpecifiedG47.33 Obstructive Sleep ApneaChief 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 PurposeNot SpecifiedBaseline DiagnosisDevice TitrationDevice EfficacySettings 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 belowSitting and ReadingNot Specified0-None1-Slight2-Moderate3-HighIn a car stopped in trafficNot Specified0-None1-Slight2-Moderate3-HighPassenger in car under an hourNot Specified0-None1-Slight2-Moderate3-HighSitting quietly after lunch without alcoholNot Specified0-None1-Slight2-Moderate3-HighLying down to rest in the afternoonNot Specified0-None1-Slight2-Moderate3-HighSitting inactive in a public placeNot Specified0-None1-Slight2-Moderate3-HighSitting and talking with someoneNot Specified0-None1-Slight2-Moderate3-HighWatching tvNot Specified0-None1-Slight2-Moderate3-HighAttach File(s)Attach authorization(s)NPIPre-populated fieldOffice ContactPre-populated fieldProvider NamePre-populated fieldUser Email User PhoneAddressAddress2CityStateZipcodeProvParameterPractice TypeFax Number This form will be submitted using the electronic signature on file