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 Intermountain Healthcare. 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 Idaho Cassia Regional Hospital Sleep Center AASM Accredited Summit Park City Hospital Sleep Center AASM Accredited iland Avenue Suite E, urley, D 83318 County ound alley r Suite , Park ity, UT Phone -667-6488 FAX: 208-677-6335 Phone -657-4443 FAX: 435-657-4365 Northern Bear River Valley Hospital Sleep Center AASM Accredited Wasatch Heber Valley Hospital Sleep Center AASM Accredited Utah North est remonton UT County (testing only) Phone -207-4500 S ighway Heer ity, UT Phone -657-444 FAX: 435-657-4365 Logan Regional Hospital Sleep Center AASM Accredited ast North, ogan UT 341 Utah American Fork Hospital Sleep Center AASM Accredited Phone -716-570 FAX: 208-677-6334 County North ast merican ork, UT 3 Phone -855-459 FAX: 801-442-0432 McKay-Dee Hospital Sleep Center AASM Accredited arrison lvd Ogden UT Utah Valley Hospital Sleep Center AASM Accredited Phone -387-270 FAX: 801-387-2709 North est Suite Provo UT, 84604 Phone -357-7771 FAX: 801-442-0432 Layton Parkway Sleep Center ayton Pwy 1A ayton T 84041 Southern St. George Regional Hospital Sleep Center AASM Phone 801-543-6925 Fax: 801-387-5640 Utah S. Medical Dr, Suite St eorge UT Phone -251-3940 FAX: 435-251-3941 Salt Lake Alta View Hospital Sleep Center AASM Accredited County South ast Sandy, UT Rural Sanpete Valley Hospital Sleep Center AASM Accredited Phone -314-2400 FAX: 801-314-2385 Utah South edical rive Mount Pleasant T Phone -462-460 FAX: 435-462-4417 Avenues Sleep Center AASM Accredited (no testing) Sevier Valley Hospital Sleep Center AASM Accredited Street Salt ae ity, UT North ain Richfield UT Phone -408-3617 FAX: 801-408-1516 Phone Scheduling: 801-855-4 FAX: 435-893-0258 IMED Sleep Center AASM Accredited (Inpatient Only) ottonwood St urray, UT 7 Fillmore Hospital Sleep Center Phone -507-9582 FAX: 801-507-9598 South wy Fillmore UT 84631 Phone -462-460 FAX: 435-462-4417 LDS Hospital Sleep Center AASM Accredited 8th Ave and St Salt ae ity, UT Delta Hospital Sleep Center Phone -408-3617 FAX: 801-408-5110 (home sleep testing only) South hite Sage venue Delta, UT 84624 Primary Children’s Hospital Sleep Center AASM Phone -462-460 FAX: 435-462-4417 (no home sleep testing or split studies) ario apecchi r, Salt ae ity, UT Phone -662-178 FAX: 801-662-1785 Riverton Hospital Sleep Center AASM Accredited S Suite Riverton UT 84065 Phone -285-487 FAX: 801-412-3160 TOSH Sleep Center AASM Accredited S Suite Murray, UT Phone -314-2400 FAX: 801-314-2385 SLEEP LAB REFERRAL FORM CPM031a - Page 2 of 2 ©2010–2020 Intermountain Healthcare. All rights reserved. .