Documents

Patient Demographics

PDF

Sleep Apnea Quiz

PDF

Epworth Sleepiness Scale

PDF

Electronic Referral Form

* Indicates required field

First Name *

ID *

Last Name *

Number *

D O B *

Email *

Gender *

Insurance *

Social Security *

Number *

Phone Number *

PCP *

Sleep Study Requested *

Primary Dx Codes: *

Supporting Dx (With a Primary Dx) *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Submit

Thank you for your business.
The intake department will process your patient and you will be able to see the status at any time in the Patient Status page.

Insurance Verification Form

* Indicates required field

Patient Name *

First

Last

Patient ID *

Number *

Insurance *

D O B *

PCP *

Ins. Ph. Number *

Gender *

PCP Number *

Policy Type *

Social Security *

1st Study? *

Policy ID *

Phone Number *

Date Last Time *

Policy Group *

Sleep Study Requested *

Policy Start Date *

Policy End Date *

In-Network Benefits

Co_Pay $ *

Deductible $ *

Is It Met? *

Met *

Remaining *

Co-Ins *

OOP $ *

OOP Met $ *

OOP Remaining $ *

Requires Pre-Authorization? *

Notes: *

Reference Number *

Agent Name: *

Out-Network Benefits

Co-Pay $ *

Deductible $ *

Is It Met? *

Met *

Remaining *

Co-Ins *

OOP $ *

OOP Met $ *

OOP Remaining $ *

Requires Pre-Authorization? *

Pre-Authorization Number *

Pre-Authorization Agent: *

Pre-Authorization Valid From-To: *

Verified By: *

Procedure Codes: *

Primary Dx Codes: *

Supporting Dx (With a Primary Dx) *

AISP Insurance References
Gonzalez and Castellanos (TAX ID: 65-0430812 NPI: 1447285606) ; DR Gonzalez (NPI: 1134152051) : DR Castellanos (NPI: 1326077967) : AISP (TAX ID: 52-2413969 NPI: 1093740235)
Next to the insurance’s name please find who they bill under. Split studies, authorization approved for both CPT codes 95810 and 95811is Required. Brenda (305) 824-3244

Medica (AISP)................................................. Commercial, Individual and Medicare Plans
Medicare (AISP)................................................................................................ No Medicaid
Molina Health Plans (AISP)
Preferred Care Partners (AISP)............................................................................... All Plans
Simply Health Plans (AISP)………………………….……..….……………….…..……All Plans
Tricare (AISP)……………………………………………….……………… ……………All Plans
United Health Care (G&C).HMO & PPO (No UHC Medicare Complete or Secure Horizons)
WellCare (AISP)....................................................................................................... All Plans
Other PPO’s.................................................................. Check with AISP prior to scheduling

Aetna (G&C) ................................................................................ EPO, PPO, POS & HMO
AvMed (AISP)............................................................................... PPO, EPO, POS & HMO
BCBS (G&C)....................... PPO, POS & Blue Options (NO HEALTH OPTIONS or HMO)
CarePlus (AISP).................................................................................................... All Plans
Cigna (G&C)..................................................................................... PPO, POS (NO HMO)
HealthSun (AISP)................................................................................................... All Plans
Humana (AISP)............................................... PPO, POS, EPO, HMO (with Authorization)
Leon Medical Centers Health Plan (AISP)............................................................. All Plans

Submit