DropShip Online Medical Order – Snap Diagnostics, LLC

Online Order

Complete the form below and submit to order a DropShip Home Sleep Test

Complete form and submit to order a home sleep test.

DROPSHIP - Home Sleep Test Order

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

HEALTHCARE PRACTICE INFORMATION

A sleep test is governed by the FDA to require a prescription by a licensed healthcare provider.

Name of Provider Ordering the Sleep Test *

First

Last

Date of Order *

ORDERING PROVIDER SIGNATURE: By my signature below I confirm that 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. *

How will you indicate your practice information? *

I will enter our Snap Center ID number.
I will enter our practice name and address.

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

CPT Code will be G0399, 95806 or 95800. The ICD‐10 code: Default to G47.30 or Enter other Code below

PATIENT INFORMATION

Completion of this section is critical for a timely testing session.

Patient Name *

First

Last

Patient Date of Birth *//

Patient Gender Identification *

Male
Female
Other

Patient Cell Phone *

Patient Home Phone (Optional)

Patient Email (Optional)

Confirm Email

Patient Home Address *

Address Line 1

City

State / Province / Region

Postal Code

Patient Height (enter feet)

Patient Height (enter inches)

Patient Weight (in pounds)

Patient Neck Size (in inches) measured at adam's apple

Please upload 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, when the patient wants to bill their health insurance for the sleep test.

Does patient have a Medical Insurance Policy?

Does patient have a Secondary Medical Insurance Policy?

Is this a repeat sleep test for this patient? *

Enter any other special instructions you want us to know (Optional).

ALTERNATE CONTACT FOR PATIENT (Optional)

An alternative contact can assist Snap in reaching the patient in a timely manner.

Name of alternative contact for patient

First

Last

Phone for alternative contact

PROVE YOU'RE HUMAN

Enter the answer to the math problem below. *

What is 7+6?

Name

Thanks for the referral. We’ll take it from here.

What happens next?

One of our support team members will reach out to your patient. After speaking with the patient we will send a Snap Home Sleep Test kit to the patient’s home.

The sleep test is simple to operate. Video and written instructions are included on how your patient can successfully perform the test. Patients also have access to our toll-free support line.

Your patient will be instructed to return the kit to Snap as soon as the testing is complete.

A professionally trained technician will manually score the completed test and a licensed medical professional will review the test results.

The resultant Snap Test report will be sent to the healthcare provider that ordered the test.

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.