CONCIERGE SLEEP MEDICINE
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OSA – Introduction
PDF Referral Form
PDF Epworth Sleepiness Scale
PDF Sleep Apnea Quiz
Electronic Referral Form
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Indicates required field
First Name
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Phone Number
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Insurance
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Self Pay
Accendo Insurance Company
Aetna
American Family Life Assurance Co. Of Columbus
Amerigroup
Av-Med
Blue Cross and Blue Shield
Capital Health
Careplus Health
Celtic
CIGNA
Coventry
Coventry Health Plan Of Florida Inc.
Coventry Summit Health
Florida Health
Florida Health Care Plan
Freedom Health
Freedom Life
Golden Rule
Health First
Health First Health
Healthease Of Florida
Healthspring Of Florida
Health Options
Healthsun
Humana
Humana Health Ins. Co. Of Florida Inc
Magallan
Molina
Medica Healthcare
Metropolitan Life Insurance
Molina Healthcare Of Florida Inc.
Neighborhood Health Partnership
Oxford
Physicians United Plan Inc.
Preferred Care Partners
Prestige
Staywell
Sunshine
The Public Health Trust Of Dade County
Tricare (south region)
UMR
United Healthcare
Universal Health Care Plus
United Healthcare of Florida (MMA)
United Health System
Wellcare Of Florida
Last Name
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Email
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Number
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D O B
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Month/Date/Year
ID
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Passport
Driver Licence
Gender
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Male
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Number
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Social Security
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PCP
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Sleep Study Requested
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95800 Sleep Study; Unattended
95805 Multiple Sleep Latency Test
95810 Polysomnography attended 4 or more Baseline (first night with 26 channels)
95811 Polysomnography attended 4 or more Split Night (all in one night, 26 channels & CPAP)
95811 Polysomnography with CPAP Titration (second night if positive in apnea, 26 channels and CPAP Tiration)
G0398 Home Sleep Study Test (HST) with Type II portable monitor, unattended, minimum of 7 channels
G0399 Home Sleep Study Test (HST) with Type III portable monitor, unattended, minimum of 4 channels
G0400 Home Sleep Study Test (HST) with Type IV portable monitor, unattended, minimum of 3 channels •E.g. Watch-PAT devices (Itamar Medical)
Primary Dx Codes:
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327.23 OSA - Witnessd Breathing Pauses During Sleep
327.51 - Periodic Limb Movements During Sleep
333.94 - Restless Legs While Falling Asleep
347.00,01 - Narcolepsy - Daytime Sleep Attacks
780.51 - Insomnia With Apnea
780.52 - Insomnia Of Unknown Etiology
780.54 - Excessive Daytime Sleepiness/Hypersomnia
Other
Supporting Dx (With a Primary Dx)
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278.00 - Obesity
278.01 - Morbid Obesity
780.09 - Somnolence or Droesiness
780.79 - Fatigue or Malaise
786.09 - Loud or Disruptive Snoring
307.45 - Shift Work Disorder
Address
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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.
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