Odh Form 207834 PDF Details

The Odh 207834 form is a crucial document for those seeking a sleep study through the Sleep Disorder Center of Olean General Hospital. This comprehensive form must be filled out accurately and entirely by individuals or healthcare professionals to initiate a sleep study order. It requires detailed patient information including the patient's name, date of birth, social security number, contact details, and residential address. Understanding insurance coverage forms an essential part of this process, encompassing details of both primary and secondary insurance, verification of test coverage, copayment amounts, and any necessary referrals or pre-authorizations. The form allows for the specification of various tests, such as overnight polysomnography and CPAP titration, based on the patient's apnea-hypopnea index or other sleep-related issues like obstructive sleep apnea, insomnia, or narcolepsy. Moreover, it inquires about the patient's current use of CPAP or continuous oxygen therapy, their work shifts, and whether they've undergone previous sleep studies. This paperwork, which must be accompanied by the patient’s most recent office visit notes, is a vital step in diagnosing and managing sleep disorders, underscoring the importance of its thorough and precise completion.

QuestionAnswer
Form NameOdh Form 207834
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesCPT95811, uppp, sleep study order form, Tenbrock

Form Preview Example

Please fax a copy of the patient’s most recent office visit notes with this form.

THE SLEEP DISORDER CENTER OF OLEAN GENERAL HOSPITAL

 

 

 

 

SLEEP STUDY ORDER FORM

 

 

 

 

 

 

 

FAX: 716 - 3 73 - 9 3 0 2 PH: 716 - 3 73 - 9 3 0 0

 

 

 

 

 

 

 

Must be filled out completely!

 

 

 

PATIENT INFORMATION

 

 

 

 

 

 

 

 

 

 

 

Patient:

 

 

 

 

 

DOB:

 

 

SS#:

 

 

Street:

 

 

 

 

 

City, State, Zip:

 

 

 

 

 

 

 

 

 

 

 

Home phone:

 

Work phone:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.Insurance Information a. Primary Insurance:

ID #:

 

 

 

 

 

 

 

Group #:

 

Subscriber: Relationship to patient:

 

 

 

 

 

 

Insurance Verification: Is testing covered?

Yes

No

Allowable:

 

 

 

 

CoPay Amt:

 

 

 

 

 

Referral needed?

No

 

 

Yes - Referral #:

 

 

 

 

Pre-auth. needed?

 

No

 

Yes - Approval #:

 

 

 

b.Secondary Insurance:

ID #:

 

 

 

 

 

Group #:

 

 

Subscriber: Relationship to patient:

 

 

 

 

 

 

Insurance Verification: Is testing covered?

Yes

No

Allowable:

 

 

CoPay Amt:

 

 

 

 

 

Referral needed?

No

Yes - Referral #:

 

 

 

Pre-auth. needed?

No

Yes - Approval #:

 

 

 

2.Tests ordered (please check): Note: if split night criteria are met CPAP titration will be initiated.

Overnight Polysomnography plus subsequent CPAP titration (if AHI is equal to or greater than 5) CPT 95810, CPT95811

CPAP titration

CPAP Repeat Titration Study - Current Settings: BIPAP Study - Current Settings:

ASV

MWT Maintenance of wakefulness (MSLT) Multiple Sleep Latency Test

Sleep consultation with Dr. Eric Tenbrock in Olean Post-UPPP PSG Surgeon:

Post-oral device PSG Dentist:

Diet:

Is patient on CPAP? No

Yes (current setting):

 

 

 

 

Is the patient currently on continuous oxygen therapy?

No

Yes - LPM

 

If yes, may we initiate the study on room air and initiate 02 protocol if criteria are met? No Yes

Has the patient had a previous sleep study?

No

Yes - when:

Where:

 

 

 

 

If not at Olean General, please send copy of report along with this form if available.

What shift does the patient work? Day

Evening

Night

3.Diagnosis:

Obstructive sleep apnea

Obesity hypoventilation syndrome Periodic limb movement

S/P upper airway surgery Other:

Insomnia Sleep-related epilepsy Narcolepsy

REM sleep behavior disorder

I, the undersigned, certify the above-prescribed procedure is medically necessary in the documentation and/or treatment of suspected diagnosis.

Physician Name (printed):

 

Signature:

Address:

Phone:Fax:Date:

Form #: 207834 Rvsd. 04/10/2009

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