URLThis field is for validation purposes and should be left unchanged.Request for Sleep Disorders Consultation/TestingIMPORTANT: 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* MM slash DD slash YYYY Email* Preferred Language English Spanish Other Other:*SYMPTOMS must be checked in order to document MEDICAL NECESSITY Witnessed Apneas Excessive Daytime Sleepiness/Fatigue Snoring Obesity Hyperactivity Restless Sleep Nocturnal leg jerking Cardiovascular Disease (CHF-CVA-MI) Insomnia Other 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:*This field is hidden when viewing the formMD Signature (Required)MD Signature (Required)*MD NameDate MM slash DD slash YYYY SpecialtyPhoneFaxAddress 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
