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Request for Sleep Disorders Consultation/Testing

IMPORTANT: In order to expedite your patient’s treatment, please include ALL PATIENT DEMOGRAPHICS, current INSURANCE INFORMATION and PROGRESS NOTES.

Central California Alliance for Health Patients An approved Referral Authorization Form (RAF) must accompany your referral to our office.

Patient Name*

Home Phone*

Mobile Phone*

Address

Street Address City State / Province / Region ZIP / Postal Code

Date of Birth*

Email*

Preferred Language

English
Spanish
Other

Other:*

SYMPTOMS must be checked in order to document MEDICAL NECESSITY

Other:*

LOCATION

Santa Cruz
Watsonville
Monterey
Sunnyvale

Options

CARE MANAGEMENT: Complete evaluation and management, including consultation, sleep study (if needed), follow-up, CPAP Clinic, etc.
IN-LAB SLEEP STUDY: Complete in-lab sleep study attended by sleep technologist.
IN-LAB TITRATION: A sleep technologist adjusts pressure to eliminate apneas, hypopneas and snoring.
IN-HOME SLEEP STUDY: It is only appropriate for patients who meet the following criteria: 1) No significant cardiac or pulmonary disease and few medical comorbidities. 2) Insurance allowing for in-home sleep study; 3) 18 years or older
IN-HOME CPAP TITRATION: In-lab attended CPAP titration will be done if home study is not adequate.
INSOMNIA CONSULTATION Note: Sleep studies are generally not indicated for insomnia unless symptoms of sleep apnea are present.
SPECIAL INSTRUCTIONS/REQUESTS

SPECIAL INSTRUCTIONS/REQUESTS:*

MD Signature (Required)

MD Signature (Required)*

MD Name

Date

Specialty

Phone

Fax

Address

Street Address City ZIP / Postal Code

Santa Cruz
1665 Dominican Way #222
Santa Cruz, CA 95065

Watsonville
150 Carnation Dr #4
Freedom, CA 95019

Monterey
101 Wilson Rd #D
Monterey, CA 93940

Sunnyvale
260 South Sunnyvale Ave #6
Sunnyvale, CA 94087

Referral Form | Sleep Health MD

Request for Sleep Disorders Consultation/Testing

IMPORTANT: In order to expedite your patient’s treatment, please include ALL PATIENT DEMOGRAPHICS, current INSURANCE INFORMATION and PROGRESS NOTES.

Central California Alliance for Health Patients An approved Referral Authorization Form (RAF) must accompany your referral to our office.

Have Questions?
We’ll Reply Quickly.

This site uses tracking technologies

Referral Form | Sleep Health MD

Request for Sleep Disorders Consultation/Testing

IMPORTANT: In order to expedite your patient’s treatment, please include ALL PATIENT DEMOGRAPHICS, current INSURANCE INFORMATION and PROGRESS NOTES.

Central California Alliance for Health Patients An approved Referral Authorization Form (RAF) must accompany your referral to our office.

Have Questions? We’ll Reply Quickly.

This site uses tracking technologies

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Have Questions?
We’ll Reply Quickly.