Tel: 877-9-SLEEPCARE or 877-975-3372

Sleep Study Referral Form

Please complete the form below. We will contact the patient to schedule tests that you have ordered. This form is not an insurance referral. It may be necessary to provide a referral specific to your patient’s health plan.

You can also click here to download and print the form and return it by fax to 718.375.2519

Patient Information

Male Female

Referring Physician

Test Requested

  • PSG (95810) and follow-up CPAP Titration (95811) (If PSG is positive, I authorize CPAP titration)
  • PSG (95810)
  • CPAP/Bi-level Titration (95811)
  • SPLIT (95811)
  • MSLT/MWT (95805)
  • VPAP Adapt SV Study (95811)
  • Home Sleep Study Testing (95806) / (G0399)
  • Other  

I request a consult with a sleep specialist before / after sleep study.

Clinical History And Indications

  • Excessive daytime somnolence
  • Heavy snoring
  • Witnessed apneic episodes
  • Obesity/recent weight gain
  • Early morning headache
  • Hypertension
  • Cardiovascular disease

Previous sleep study Yes No

Suspected:

  • Sleep Apnea
  • Narcolepsy
  • Periodic Leg Movement Disorder
  • Other

ENT Findings:

  • Crowded oropharynx
  • Enlargement of soft palate / uvula
  • Tonsilar hypertrophy

Instructions to Polysomnographic technologist (special patient or study requirements):



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