Transcription of Sleep Study Prior Authorization Request Form
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Sleep Study Prior Authorization Request Form
1 CARECENTRIX CIGNA Sleep MANAGEMENT PROGRAM Sleep Study PRECERTIFICATION Request form Phone: Fax: This form must be completed in its entirety for all faxed Sleep services precertification requests. The most recent clinical notes must also accompany the faxed Request . We recommend that all requests for Sleep related services are submitted via our website at , you can access our provider portal to submit and upload this document at: . Patient Name: Cigna ID #: Date of Birth: Patient Address: City: State/Zip: Home #: Cell #: Work #: Height: Weight: BMI: Ordering Healthcare Professional: Ordering Healthcare Professional NPI : Ordering Healthcare Professional Address: City: State/Zip: Ordering Healthcare Professional Phone #: Ordering Healthcare Professional Fax #: I.
B. Signs & Symptoms Initial testing for the diagnosis of sleep disordered breathing is appropriate if a member presents with at least one sign/symptom from category (a) AND one sign/symptom from category (b) below: (a) Evidence of Excessive Daytime Sleepiness _____ Disturbed or restless sleep
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