Form Wh1220 PDF Details

In order to effectively manage your business, you need accurate and timely financial information. TheInternal Revenue Service (IRS) offers a number of resources to help businesses prepare and file their taxes. In this blog post, we will discuss Form Wh1220, the Business Tax Credit for Health Insurance Coverage Under a Qualified Health Plan. We will provide an overview of the form and outline the eligibility requirements for claiming the credit. Finally, we will provide some tips on how to complete the form. Stay tuned for future blog posts that will cover other IRS forms related to small businesses. Thanks for reading!

QuestionAnswer
Form NameForm Wh1220
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesSleep_Evaluatio n_Form winchester hospital sleep disorder center form

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WINCHESTER HOSPITAL

Winchester, Massachusetts

Sleep Disorders Center

Baldwin Park I, Suite 110

12 Alfred Street, Woburn, MA 01801

Phone: 781-756-2325 Fax: 781-756-7045

SLEEP EVALUATION FORM

PATIENT INFORMATION

Name _______________________________________________ DOB _______________ MR# ____________________

Home Phone _________________________________________ Work/Cell Phone _______________________________

Primary Physician _____________________________________ Requesting Physician ___________________________

If sleep consult desired prior to sleep study, please contact one of the sleep physician listed below directly.

PATIENT IS BEING REFERRED FOR:

Sleep Study Only

Results sent to referring physician for further management.

Diagnostic Sleep Study

Full night polysomnography (PSG). If patient meets AASM

criteria, CPAP may be started.

*If Diagnostic study only is requested, please check here. Reason _________________________________________

CPAP or BIPAP Titration/Retitration

Titration for patients with OSA documented by prior PSG.

*Diagnostic Sleep Study with Multiple Sleep Latency Test (MSLT) or Maintenance of Wakefulness Test (MWT). Diagnostic sleep study followed by a daytime nap test to diagnose narcolepsy or excessive daytime sleepiness.

*Both studies must be ordered by a neurologist, pulmonologist or sleep physician.

If PSG is abnormal, consultation with interpreting physician is requested for evaluation and management.

Please initial if this is desired _____________

Is patient going to be seen or has patient been seen in the past by one of the following:

*Please choose Sleep Reader/Consultant below

Albanese

 

Patwa

Bader

 

Taylor

 

Chervin

 

Zaslow

 

Gebhardt

 

 

*No Preference - reading MD through rotation

MEDICAL HISTORY (history and physical examination is required). Please fax office notes/progress notes with request.

Weight _______________ lbs.

Height _________________

BMI ____________

Neck Size _______________ in.

Suspected Disorder(s)

Obstructive Sleep Apnea (OSA) Narcolepsy

Nocturnal Seizures/Parasomnias Insomnia

Restless legs syndrome (RLS) or periodic limb movements of sleep (PLMS)

Primary Symptoms

Snoring/gasping/choking Witnessed apnea Obese/large neck Daytime sleepiness Difficulty falling asleep Fragmented sleep

Frequent leg movements during sleep Preoperative assessment

Special Needs

Nocturnal O2 - Level: _________

Wheelchair Currently using PAP -

Pressure (cm): ____________

Other: _____________________

Medications/comments ________________________________________________________________________________________

___________________________________________________________________________________________________________

Please Circle

PMH: HTN DM COPD CAD CHF Depression Other

Physician's Signature _____________________________________________ Date/Time ________________________

WH1220 (01/10)