SLEEP CENTER REFERRAL FORM

PATIENT INFORMATION REFERRING PROVIDER Name: ______Provider Name: ______DOB: ______NPI: ______Phone: ______Office Phone: ______Insurance: ______Office Fax: ______

Prior-Authorization Obtained by Sleep Center ☐ Clinic notes with a sleep diagnosis and demographic information including insurance are required to complete this referral. ORDER FOR SLEEP CONSULTATION AND MANAGEMENT (Recommended)

☐ The sleep specialist will manage testing, treatment, and follow up. Our Sleep Navigators will review your patient’s history and determine appropriate next steps for consultation and sleep testi ng. We will arrange for appropriate diagnostic and therapeutic procedures. We will also arrange for therapy and follow up on compliance milestones. Checking this box does not require an order for sleep testing

ORDER FOR SLEEP TESTING (Optional)

Home Sleep Apnea Test (HSAT) (Home Testing is recommended for patients with a ☐ high likelihood for sleep apnea; please see contraindications for home sleep testing below) Reason for referral (STOP-Bang) ☐ Diagnostic Polysomnography (No CPAP) ☐ Snoring ☐ BMI (> 35) ☐ Split-night Polysomnography (Use of American Academy of Sleep Medicine (AASM) criteria recommended) ☐ Tired ☐ Age (>50) Observed Apnea Neck (>16) ☐ Full night CPAP Titration (Patient must have documented diagnosis of OSA by HSAT ☐ ☐ or PSG; if no diagnostic study, consider repeat PSG, Split-night or consultation) ☐ ☐ Pressure (HBP) Gender (Male)

Special Instructions/Other: ______All testing will be conducted on room air and will follow American Association of Sleep Medicine (AASM) and Sleep Other: ______Center Oxygen/PAP guidelines unless specifically ordered otherwise. ☐

Follow-up management:

☐ Sleep center will manage treatment, equipment, follow up and compliance

☐ I will follow-up and treat, including ordering all necessary equipment, supplies and monitoring of compliance HOME SLEEP APNEA TEST (CONTRAINDICATIONS) (Mark all that apply)

Narcolepsy (History or suspicion) ☐ None ☐ Neuromuscular/neurodegenerative disorder ☐ BMI ≥ 50 ☐ Obesity hypoventilation syndrome ☐ Cardiovascular disease, CHF, dysrhythmia, or stroke ☐ Parasomnia (History or suspicion) ☐ Central sleep apnea ☐ Pulmonary disease ☐ Cognitive impairment ☐ Significant Insomnia Chronic opioid use ☐ ☐ Note: Our sleep labs do not dispense medications. If a sleep aid is needed, prescribe prior to study and instruct patient to take to the lab and self-administer.

Provider Signature: ______Date: ______Time: ______No stamp signatures please

SLEEP LAB REFERRAL FORM CPM031a - Page 1 of 2 ©2010–2020 . All rights reserved. *50261* (See sleep specialist and sleep lab contact information on page 2.) Order 50261 INTERMOUNTAIN SLEEP CENTERS CONTACT INFORMATION:

Sleep Center Sleep Center Cassia Regional Hospital Sleep Center AASM Accredited Summit Sleep Center AASM Accredited iland venue Suite urley County ound alley r Suite ar ity hone FAX: 208-677-6335 hone FAX: 435-657-4365

Northern Bear River Valley Hospital Sleep Center AASM Accredited Wasatch Heber Valley Hospital Sleep Center AASM Accredited North est remonton County (testing only) hone S ighway eer ity hone FAX: 435-657-4365 Sleep Center AASM Accredited ast North ogan Utah Sleep Center AASM Accredited hone FAX: 208-677-6334 County North ast merican or hone FAX: 801-442-0432 McKay-Dee Hospital Sleep Center AASM Accredited arrison lvd Ogden Hospital Sleep Center AASM Accredited hone FAX: 801-387-2709 North est Suite rovo hone FAX: 801-442-0432 Layton Parkway Sleep Center ayton wy ayton Southern St. George Regional Hospital Sleep Center AASM hone Fax: 801-387-5640 Utah S edical r Suite St eorge hone FAX: 435-251-3941 Salt Lake Sleep Center AASM Accredited County South ast Sandy Rural Sleep Center AASM Accredited hone FAX: 801-314-2385 Utah South edical rive ount leasant hone FAX: 435-462-4417 Avenues Sleep Center AASM Accredited (no testing) Sleep Center AASM Accredited Street Salt ae ity North ain ichfield hone FAX: 801-408-1516 hone Scheduling FAX: 435-893-0258 IMED Sleep Center AASM Accredited (Inpatient Only) ottonwood St urray Fillmore Hospital Sleep Center hone FAX: 801-507-9598 South wy illmore hone FAX: 435-462-4417 LDS Hospital Sleep Center AASM Accredited th ve and St Salt ae ity Delta Hospital Sleep Center hone FAX: 801-408-5110 (home sleep testing only) South hite Sage venue elta Primary Children’s Hospital Sleep Center AASM hone FAX: 435-462-4417 (no home sleep testing or split studies) ario apecchi r Salt ae ity hone FAX: 801-662-1785

Riverton Hospital Sleep Center AASM Accredited S Suite iverton hone FAX: 801-412-3160

TOSH Sleep Center AASM Accredited S Suite urray hone FAX: 801-314-2385

SLEEP LAB REFERRAL FORM CPM031a - Page 2 of 2 ©2010–2020 Intermountain Healthcare. All rights reserved.