BCOH Sleep Apnea Referral

Patient's Information

Your Name (required)

Patient's Email

Your Email (required)

Patient's Address

Patient's Phone Number

Patient's DOB

Requesting Physician's Information

Sleep Study Available:

YesNo

Reason for referral (Mark all that apply)

Diagnosis:

Obstructive Sleep Apnea (ICD 327.23)Hypersomnia due to Sleep Apnea (ICD 780.53)Insomnia due to Sleep Apnea ( ICD 780.51)Other , unspecified (ICD 780.57)

Baseline Data (without CPAP or Oral Appliance)

AHI

RDI

Lowest Desaturation (SpO2)

T90

Therapies attempted:

CPAP
IntolerantNot a good candidate
Surgery
YesNo

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