DOT – FastMed Online Referral Form – Snap Diagnostics, LLC

Complete form and submit to order a home sleep test.

FastMed Sleep Test Medical Order

NOTE: After you "submit" this order you will be presented an option to print or save the completed order. Form Version: WEB-FastMed-QF-54805 revA

Select your FastMed Urgent Care Clinic *

Please select the option "Location not found on list" if you cannot find your FastMed Clinic location. We will add the location to the list after your first patient referral.

FastMed Medical Provider's Name *

First

Last

FastMed Provider NPI Number *

CPT Code will be G0399 or 95806. The ICD‐10 code: Default to G47.30 or Enter other Code below

Test Ordered: Type 3, unattended home sleep test for up to three nights or enter alternative number of nights below.

Date of Order *

FASTMED PROVIDER: By my signature below I attest that I am a FastMed Medical Provider, and I hold a valid healthcare license and I attest that based on my examination of the patient and his/her medical history, there is a high probability of Obstructive Sleep Apnea. An unattended, type 3, Home Sleep Test with a minimum of 4 channels (airflow, respiratory effort, SpO2 saturation and heart rate), is medically necessary. No co‐morbid conditions including, but not limited to, moderate to severe COPD, CHF, OHS, neurodegenerative disorder or cognitive impairment are present that prevent the patient from home sleep testing. *

SLEEP TEST PATIENT INFORMATION

Patient Name *

First

Last

Patient Birth Date *//

Patient Gender *

Patient Height (enter feet)

Patient Height (enter inches)

Weight (in pounds)

Neck size (in inches): Measured at adam's apple

STOPBANG Score *

Patient Phone *

Patient Address *

Address Line 1

City

State / Province / Region

Postal Code

Patient Email

Confirm Email

Please upload the DOT Long Form from your exam OR the Clinical Note from the face-to-face encounter with the patient when the sleep test was ordered.

This information is required by health insurance and will improve the time needed to complete the testing process if patient wants to bill their health insurance for the sleep test.

ALTERNATE CONTACT - If available

Name of alternate contact

First

Last

Relationship of alternative contact to patient

Phone for alternate contact

Enter the answer to the math question *

What is 7+9?

Name

FastMed Sleep Apnea DOT Support Page

You can use the button below to return to the FastMed Sleep Apnea DOT Support page.

NOTE: If you are making an online patient referral, please submit your referral first so you do not lose the information 🙂

DOT Support

Complete form and submit to order a home sleep test.

SLEEP TEST PATIENT INFORMATION

ALTERNATE CONTACT - If available

FastMed Sleep Apnea DOT Support Page

Any patient status updates you enter on your portal are instantly communicated to the Ordering Provider's Patient Portal.

The Master Admin can add an unlimited number of additional login accounts for their organization. Turn notifications ON to get email alerts.

You can transfer any patient to another treatment provider.
The patient will move off your portal and instantly be shown on the portal for the Treatment Provider you selected.
The Ordering Provider's Patient Portal will also instantly reflect the new Treatment Provider.

Sending a patient to Snap for an HST is as Easy as 1, 2, 3.
Select the Ordering Provider for the HST.
Enter a few patient details.
Upload the Medical Order from the Ordering Provider.

This is the information we need to setup the TX Provider Account.
Please gather all of the information shown and send to Snap personnel.