Provider Order Form DemographicsName* First Last Date of Birth* Date Format: MM slash DD slash YYYY Primary Phone*Secondary PhoneEmail Address* Street Address Address Line 2 City ZIP / Postal Code Insurance InformationPrimary Insurance*Policy NumberGroup NumberSleep Medicine ServicesRequested Sleep Medicine Services* Complete Evaluation and Management 1st Night Full Channel In-Lab Study (no CPAP) 2nd Night Full Channel In-Lab Study (with CPAP) Split Night Full Channel In-Lab Study Limited Channel Home Sleep Apnea Test **Please upload clinical visits and prior sleep studies to all orders**If a full channel study is not appropriate, by insurance or patient, a Limited Home Sleep Apnea Test (HSAT) will be performed.* Agree Disagree - Call if orders need to be changed ObservationsClinical Heavy Snoring Anxiety Depression Hypertension Diabetes Obesity Witnessed Apnea Suspicion of Sleep Apnea Insomnia Narcolepsy Bruxism (teeth grinding) Narcolepsy Restless Leg Syndrome Restless Leg Movement Previous Diagnosis Obstructive Sleep Apnea Currently on PAP therapy Currently on Dental Appliance Periodic Leg Movements Insomnia Narcolepsy Epworth Sleepiness Scale ResultsPlease enter a number from 0 to 24.Additional NotesProvider InformationPractice Name*Provider Name* First Last Suffix Provider NPIPractice PhoneAddress* Street Address Address Line 2 City ZIP / Postal Code Office Point of ContactPoint of Contact Email I prefer to interpret my patient's sleep study results. Yes Interpeting Doctor NameUpload Clinical Notes, Insurance Referrals, Sleep Studies and Orders Drop files here or Agreement/E-Signature Disclaimer* I agree By selecting the "I agree" checkbox, you agree to the following: You are 18 years of age or older. You acknowledge the risk of sending information by email and will not hold Texas Sleep Docs liable for any damages you may incur as a result of the transfer or use of this information. The use or transmittal of this form does not create a physician-patient relationship.NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.