Get Home Sleep Test (hst) Order Form: You May ... - Novasom

The Home Sleep Test (HST) Order Form from NovaSom is an essential document for requesting a sleep test to diagnose obstructive sleep apnea. This guide provides a comprehensive, step-by-step approach to help users fill out the order form accurately and efficiently.

Follow the steps to complete the form effectively.

1. Click the 'Get Form' button to access the Home Sleep Test Order Form. This will allow you to open and edit the document easily.
2. Begin by filling out the Prescriber Information section. Enter the ordering provider's name, phone number, fax number, NPI, and office contact name. If applicable, include the contact's phone number with extension.
3. Next, proceed to the Patient Information section. Enter the patient's last name, first name, date of birth, gender, height, weight, state, zip code, address, city, cell phone number, home phone number, and email. Ensure that the address includes any apartment number and that a P.O. Box is not listed.
4. In the Payment/Insurance section, choose whether the patient is requesting self-payment or insurance billing. If self-payment is selected, indicate that the amount is $297 and specify the payment plan. If insurance billing is chosen, attach copies of the insurance card's front and back, and complete the Primary and Secondary Plan details.
5. Continue to the Diagnosis/Medical History/Symptoms section. Note that the ICD-10 code G47.33 will be used by default for the obstructive sleep apnea test. Check at least two symptoms from the list provided, and if required, attach medical documentation regarding testing for sleep apnea.
6. Indicate whether the patient has congestive heart failure (CHF) or chronic obstructive pulmonary disease (COPD). If applicable, specify the severity of COPD as mild, moderate, or severe. Also, enter the patient's Epworth Sleepiness Scale Score if available.
7. Specify the test type to be administered; by default, a Home Sleep Test will be conducted unless otherwise indicated. Fill out information regarding the Titration Test if necessary.
8. In the Designated Therapy/Durable Medical Equipment (DME) Provider section, enter the contact details of the therapy/DME provider to whom results should be sent. This allows coordinated care for the patient.
9. Finally, the prescriber must sign the form confirming that they find the Home Sleep Test medically necessary. Include the date of signing. Ensure that the signature is original, as stamped signatures are not accepted.
10. Once completed, save your changes, and print or share the document as necessary. You can submit the form via fax or online for processing.

Complete your HOME SLEEP TEST (HST) ORDER FORM online to ensure accurate and efficient processing.