Doctor Referral Form

When you complete and submit this form, the referral order will be sent to Alpha Fertility & Sleep Center. Please make sure all the information is correct before you submit it.

You will receive a copy at the physician’s email address you provide, this may take a few hours.

PATIENT’S INFORMATION

Patient Name:

Patient’s email address

DOB:

Patient’s phone number:

PLEASE ATTACH:

DEMOGRAPHIC SHEET

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HISTORY & PHYSICAL

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Or email these documents to info@alphasleepcenter.com in the next 24 hours.

Study Ordered:

Full Sleep Evaluation (HST 95806, Diagnostic 95810, Titration 95811, MWT 95805, MSLT 95805, 95816, 95957, 93005, 99211)

First Night Sleep Study NPSG Diagnostic - CPT: 95810 (In-Lab)

Second Night Sleep Study CPAP/BiPAP Titration - CPT: 95811 (In-Lab)

Home Sleep Test up to Three Nights- CPT: 95806, A9900

MSLT- Multiple Sleep Latency Test- CPT: 95805 (In-Lab) (Preceded by CPT 95810)

MWT- Maintenance of Wakefulness Test- CPT: 95805 (In- Lab) (Preceded by CPT 95810)

PAP NAP (Daytime Abbreviated Sleep Test) - CPT: 95807 (In-Lab)

Other Testing:

Please Include:

Height:

Weight:

BMI:

Age:

Epworth Score:

Neck Circumference:

Does the patient have any special medical or physical needs? Please describe:

Does the patient require a family member to stay at night? (For a medical reason only)

PHYSICIAN INFORMATION

Physician Name:

Physician Phone:

Today's Date

Physician Address:

City / State / ZIP

Physician email:

Submitted by (employee name):

Physician Fax:

Digital Signature: By checking this box you confirm you are a certified physician or that you represent the physician whose name you provided.

IMPORTANT WARNING: This document, including any attachments, is intended for the use of Alpha Fertility & Sleep Center, LLC and may contain information that is privileged and confidential, the disclosure of which is governed by applicable law. If the reader of this fax transmission is not the intended recipient, or the employee or agent responsible to deliver it to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this information is STRICTLY PROHIBITED. If you have received this fax in error, please notify us immediately and destroy any copies you possess.

Thanks for submitting!