Complete the form below as thoroughly as possible, then click on the "Generate RX Form" button to create the prescription, you can print the page, sign and date it, and then fax it in to SleepQuest.
Patient Information:
Patient Name:
Date of Birth:
Patient Address:
Patient City:
Patient State:
Patient ZIP:
Patient Phone:
In-Home Study Justification:
If the patient has Blue Cross, please select a justification from the list below.
Patient presents with severe clinical symptoms highly suspicious for obstructive sleep apnea, and standard in-lab PSG is not readily available.
Patient is unable to be studied in a sleep lab.
Follow up to a previous sleep lab study.
Patient has a high pre-test probability of moderate to severe OSA, and all of the following are present: habitual snoring, witnessed apnea, an Epworth Sleepiness Scale score greater than 10, and obesity with a BMI >30; and who is without evidence of a significant medical comorbidity or other sleep disorders.
Additional/Custom Justification
Diagnosis(s):
Primary Diagnosis:
Hypersomnia With Sleep Apnea (780.53)
Unspecified Sleep Apnea (780.57)
Insomnia With Sleep Apnea (780.51)
Central sleep apnea (327.27)
Obstructive sleep apnea (327.23)
Unspecified Hypertension (401.9)
Hypersomnia, Unspecified (327.10)
Insomnia, Unspecified (327.00)
Additional Diagnosis:
Additional Diagnosis:
Additional Diagnosis:
Physician Information:
Physician Name:
Physician Address:
Physician City:
Physician State:
Physician ZIP:
Physician Phone:
Physician Fax:
Physician NPI #:
Physician UPIN #:
SleepQuest Location:
(Leave blank if you are unsure)
