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57 Insomnia with sleep apnea unspecified 780. 51 Insomnia nec 780. 52 Narcolepsy 347. 0 Parasomnia organic 327. SLEEP CONSULTATION/REFERRAL REQUEST FORM Referring Physician Name Address Phone Fax To Healthplex Family Clinic LLC Name Dr. 40 Hypersomnia non-organic origin 307. 43 RLS/PLMS 327. 52 Period limb movement disorder 327. 51 Sleep related movement disorder unspecified 780. Mary Beth Valiulis / SLEEP SPECIALIST Address 9425 Healthplex Drive Suite 101 Shreveport Louisiana 71106 Phone/Fax...
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How to fill out sleep consultationreferral request form
How to fill out sleep consultationreferral request form
01
Gather all necessary information such as personal details, relevant medical history, and sleep-related concerns.
02
Obtain a copy of the sleep consultation/referral request form from the designated source.
03
Read the instructions provided on the form carefully to ensure proper completion.
04
Fill out the form accurately and legibly, following the specified format.
05
Provide all required information, including identification details, contact information, and any specific instructions or preferences.
06
Include any relevant medical history, such as prior sleep studies, diagnoses, or treatment received.
07
Clearly state the reason for the sleep consultation/referral and any specific concerns or symptoms experienced.
08
Double-check the completed form for any errors or missing information.
09
Submit the form as instructed, whether by mail, fax, or electronically.
10
Retain a copy of the completed form for your records.
Who needs sleep consultationreferral request form?
01
Individuals seeking professional advice or consultation for sleep-related issues or disorders.
02
Patients experiencing chronic insomnia, sleep apnea, narcolepsy, restless legs syndrome, or other sleep disturbances.
03
People with excessive daytime sleepiness, difficulty falling or staying asleep, frequent nightmares, or abnormal sleep behaviors.
04
Individuals referred by their primary care physicians or other healthcare providers for further evaluation or treatment.
05
Those interested in undergoing sleep studies, diagnostic evaluations, or receiving specialized sleep-related care.
06
Parents or caregivers seeking assistance for children with sleep problems or disorders.
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What is sleep consultation/referral request form?
The sleep consultation/referral request form is a form used to request consultation or referral for sleep-related issues.
Who is required to file sleep consultation/referral request form?
Patients or healthcare providers who require consultation or referral for sleep-related issues are required to file the form.
How to fill out sleep consultation/referral request form?
The form can be filled out by providing patient information, details of the sleep issue, and the reason for the consultation or referral.
What is the purpose of sleep consultation/referral request form?
The purpose of the form is to facilitate the process of seeking consultation or referral for sleep-related issues.
What information must be reported on sleep consultation/referral request form?
The form must include patient information, details of the sleep issue, and the reason for consultation or referral.
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