For Physicians
Service Request Form
Use the form below to refer a patient for Home Sleep Testing (HST) or PAP Therapy. Download, complete, and fax or email the signed form with supporting documentation.
Download the Form
Two versions are available. The fillable PDF can be completed on-screen before printing. The non-fillable version is for handwriting.
How to Submit
Complete all patient information, history & symptoms, and select the requested service.
Physician must sign and date the form. Medicare patients require PECOS-certified physicians.
Attach H&P or progress notes and a copy of the patient's insurance card.
Fax the completed packet to (877) 855-6227 or email to orders@sleepdr.com.
Services Covered
Home Sleep Test (HST)
CPT codes: 95806, 95800, G0399, G0400. Includes professional interpretation by a qualified ASMS physician.
HST with Oral Appliance
Combined home sleep test with oral appliance evaluation. PPO, Medicare, or cash pay only.
PAP Therapy — Device
APAP or CPAP device supply. Default APAP settings: 4–20 cm/H₂O. Partner company referral.
PAP Therapy — Supplies
Ongoing supplies: masks, tubing, humidifier, filters, and accessories per schedule of need.
Medicare patients: The referring physician must be PECOS certified. We can only send records to the fax number we have on file. If records need to be sent to a different fax number, call us at (877) 775-3377.
Submit Your Order
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