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PLEASE FAX FORM TO: Sleep Care at MidState Medical Center FAX: (203) 694-8885 PHONE: (203) 694-8887 Ordering Physician: ______________________________________________ Address: _______________________________________________________ Phone#: _________________________ No. Pages _______ Date: _______________ PRESCRIPTION FOR SLEEP STUDY PATIENT NAME: ___________________________________ DOB: ___________ ADDRESS: ____________________________________________________ PHONE: Home ______________Work _______________ Cell_______________ SLEEP SPECIALIST: Dr. Brett Volpe EVALUATE FOR: (please check appropriate diagnosis) Sleep Apnea with Hypersomnia G47.30 Obstructive Sleep Apnea G47.33 Central Sleep Apnea G47.31 Restless Legs Syndrome G25.81 PLMS G47.61 Excessive Daytime Sleepiness G47.10 Narcolepsy w/o cataplexy G47.419 Morbid Obesity E66.01 Other ____________________________________ COMPREHENSIVE SLEEP EVALUATION (SLEEP SPECIALIST AND PSG) STUDY PRESCRIBED: PSG (Polysomnogram) CPAP/BiPAP Split Study MSLT (for narcolepsy) MWT PRIMARY INSURANCE: ________________Insurance ID #____________________ SECONDARY INSURANCE: _____________Insurance ID#_____________________ PLEASE FAX COPY OF INSURANCE CARD WITH PRESCRIPTION Physician Signature _______________________ Physician Lic#/Tax ID# ________________
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