HOME SLEEP TEST (HST) ORDER FORM: Submit via Fax to: 18662165200 or : 4106305845 You may also order online at www.novasom.com/easyorder For assistance, please contact NovaSom at 18777533776 For faster.
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How to use or fill out the HOME SLEEP TEST (HST) ORDER FORM: Submit Via ... - NovaSom online
Filling out the Home Sleep Test (HST) Order Form is a crucial step in facilitating your sleep evaluation process. This guide provides step-by-step instructions to ensure a smooth and comprehensive completion of the form.
Follow the steps to accurately complete the Home Sleep Test order form.
- Click 'Get Form' button to obtain the form and open it in the editor.
- In the 'Prescriber Information' section, enter the ordering provider's name, phone number, fax number, and NPI if this is the first order. Also, include the office contact name and their phone number if applicable.
- Fill in the 'Patient Information' section by providing the patient's first name, last name, date of birth, gender, height, weight, state, zip code, address (including any apartment number and excluding P.O. Box), city, primary phone, alternate phone, and the language spoken if not English.
- In the 'Payment/Insurance' section, choose one option: whether the patient requests self-payment of $297 or insurance billing. If selecting insurance billing, attach a copy of both the front and back of the insurance card and complete the details of the primary and secondary insurance plans.
- In the 'Diagnosis/Medical History/Symptoms' section, the default ICD-9 code of 327.23 will be used unless a different code is specified. Check at least two symptoms from the list provided that apply to the patient. Ensure to attach any necessary medical documentation related to sleep apnea testing.
- Record the Epworth Sleepiness Scale score within the given range (0 – 24), noting that a score greater than 10 indicates high risk.
- Select the specific type of test the patient will undergo. The options include Home Sleep Test Only, Home Sleep Test including Titration Test, and Titration Test Only. If applicable, provide details regarding the last sleep test conducted.
- In the 'Designated Therapy/Durable Medical Equipment (DME) Provider and Release of Test Results' section, enter the contact information of the therapy/DME provider to direct test results to them.
- Finally, provide the provider’s original signature to attest the medical necessity of the home sleep test, along with the date of signing the form.
- Once all sections are completed, save changes, download, print, or share the form as needed.
Complete your Home Sleep Test Order Form online today to expedite your sleep evaluation process.
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