Odh Form 207834 PDF Details

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.

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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