Do you need to fill out the Odh Form 207834? It can be a tricky form to navigate, so read on for a professional and informative guide. We’ll discuss what it is, why you are required to fill it out, who completes the form and when, how detailed the information should be that you provide, and any potential consequences of failing to accurately complete this government-mandated document. With everything from deadlines and formatting requirements explained in plain language with examples included where needed, armed with this knowledge you will have all the tools necessary to make sure your Odh Form 207834 submission meets both accuracy criteria and timely filing marks.
Question | Answer |
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Form Name | Odh Form 207834 |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | CPT95811, uppp, sleep study order form, Tenbrock |
Please fax a copy of the patient’s most recent office visit notes with this form.
THE SLEEP DISORDER CENTER OF OLEAN GENERAL HOSPITAL
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SLEEP STUDY ORDER FORM |
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FAX: 716 - 3 73 - 9 3 0 2 PH: 716 - 3 73 - 9 3 0 0 |
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Must be filled out completely! |
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PATIENT INFORMATION |
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Patient: |
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DOB: |
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SS#: |
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Street: |
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City, State, Zip: |
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Home phone: |
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Work phone: |
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1.Insurance Information a. Primary Insurance:
ID #: |
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Group #: |
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Subscriber: Relationship to patient: |
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Insurance Verification: Is testing covered? |
Yes |
No |
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Allowable: |
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CoPay Amt: |
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Referral needed? |
No |
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Yes - Referral #: |
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No |
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Yes - Approval #: |
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b.Secondary Insurance:
ID #: |
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Group #: |
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Subscriber: Relationship to patient: |
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Insurance Verification: Is testing covered? |
Yes |
No |
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Allowable: |
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CoPay Amt: |
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Referral needed? |
No |
Yes - Referral #: |
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No |
Yes - Approval #: |
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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
Diet:
Is patient on CPAP? No |
Yes (current setting): |
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Is the patient currently on continuous oxygen therapy? |
No |
Yes - LPM |
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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: |
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Where: |
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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
REM sleep behavior disorder
I, the undersigned, certify the
Physician Name (printed): |
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Signature: |
Address:
Phone:Fax:Date:
Form #: 207834 Rvsd. 04/10/2009 |
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