- The name, phone numbers, date of birth, height and weight of the patient being referred to the facility must be completed.
- The name of the requesting physician must be filled in.Section B: Patient Evaluation/Risk Stratification
- Check all appropriate indication in columns A and B.
- Complete oxygen administration information as requested.
- List all special needs, (i.e., wheelchair bound, interpreter, special diet, must be accompanied by caregiver, etc.)
- Attach pertinent patient information. The requesting physician must provide as much information as possible in this section of the referral form. This information includes a diagnosis, pertinent medical history, symptoms leading to referral, current medication, surgical history, CPAP or supplemental oxygen use, and any additional information that may be essential in assessing and providing the correct sleep study for the patient.
- In order to prioritize patients based upon the severity of their symptoms, the referring physician must declare the relative level or urgency assigned to the referral.
Section C: Referring Physician's Signature
- The referral form must be signed and dated by the physician requesting the sleep study review.