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Download The Sleep Center at MedStar National Rehabilitation Hospital
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The Sleep Center at MedStar National Rehabilitation Hospital Please fax this form to: 202-722-6322 Prescription Order Form 102 Irving Street, NW Washington, DC 20010 Voice Line: 202-877-1683 Last Name:_______________________________________________ First Name: __________________________________ *D.O.B.__ __ __ __ __ __ Address: ____________________________________________________________________________________________________________________________ ADMIN City/State: _______________________________________________________________________________________Zip Code:______________ SEX: M or F Home #: _____________________________________________Work #:__________________________________Other #:________________________________ Referring Dr. ________________________________________________ *Phone #:____________________________ *Fax #:____________________________ *NPI # (Ref MD) ________________________________________ DC Medicaid Prov. ID ______________________________________ (if Medicaid patient) PCP:_________________________________________________________________________________________________________________________________ *All Medicare patients must have consults before sleep study. Documentation and office notes are required with referral. *Insurance (attach/submit copy of insurance card). If HMO, referral is required. Please attach. If no card, insurance ID # _____________________________________________________________________________________________________________ *DIAGNOSIS SUSPECTED c Obstructive Sleep Apnea c REM Behavior Disorder c Parasomnias or Seizures c Periodic Leg Movement c Insomnia c Narcolepsy c Restless Leg Syndrome c Other:_____________________ *CLINICAL OBSERVATIONS / INDICATIONS c Witnessed Apnea c Daytime Sleepiness c Snoring c Restless Sleep c Hypertension c Obesity c Morning Headache c Frequent Napping c Sleep Walking/Talking *RELEVANT HISTORY/PHYSICAL Kindly fax copy of H&P or complete following information Height: _______________ in Weight: _______________ lbs Blood Pressure:_______________ Pulse:_______________ Medications: __________________________________________________________________________________________________________ History: ______________________________________________________________________________________________________________ *PHYSICAL FINDINGS: MEDICAL INFO HEENT c Normal c Abnormal — define ___________________________ *ICD-9 Codes Cardiac c Normal c Abnormal — define ___________________________ c 401.9 Hypertension Pulmonary c Normal c Abnormal — define ___________________________ c 780.53 Hypersomnia w/Sleep Apnea, Neurologic c Normal c Abnormal — define ___________________________ G.I. c Normal c Abnormal — define ________________________ (unspecified) c Other__________________________ *SPECIAL NEEDS: (i.e., diet, language, oxygen requirement) ____________________________________________________________________ *SERVICES REQUESTED (please check one) c Consultation with Sleep Specialist: This is highly recommended for physicians who do not treat sleep disorders on a regular basis. Consulting physician will evaluate the patient, order appropriate sleep tests, provide follow-up care, and arrange CPAP/DME equipment. Feedback will be given to referring physicians. For HMO patients, a separate referral may be necessary. c Full Service Sleep Order: Standard Sleep Study and Titration Study (if positive for moderate to severe sleep apnea). Referring physician is responsible for ordering any CPAP/equipment and patient care once study is completed. c c c c c Full night CPAP titration. Responsibility to order equipment and provide follow up remains with the referring physician. Split night Study: 2 hour baseline PSG. If clearly positive, this is followed by an abbreviated CPAP titration. Mutiple Sleep Latency Test (MSLT) preceded by PSG if not recently done. To assess for sleepiness and narcolepsy. Maintenance of Wakefulness Test (MWT) to assess capacity to stay awake while driving or at work. Polysomnogram with Seizure montage EEG. For nocturnal events in which seizures are in the differential diagnosis. I authorize NRH to perform services on the above patient according to the clinical protocols approved by the Medical Director. PHYSICIAN SIGNATURE (required)* ___________________________________________________________________ DATE__________________ MedStar NRH Sleep Center is accredited by the American Academy of Sleep Medicine. It is requested that the Prescription Order Form be completed in entirety. Thank you * = Required fields 0213
