Assessment Form

Sleep Study Service(s) Required
(PLS COMPLETE MEDICARE ELIGIBILITY CRITERIA OVERLEAF)
Sleep Study Service(s) Required
- Home-based Sleep Study - For suspected sleep apnoea
- Sleep Physician Consultation - Patient review by a Norwest Respiratory Physician
Please tick all applicable boxes.
Home-based Sleep Study
- Assess PAP
- MAS
- Positional therapy

Referring Doctor
Doctor
- GP
- Physician
Specialty
Name
Provider No
Address
Telephone
Fax
Email
Date
Month
Day
Year
How would you like to receive the report for patient review?
- Email
- Fax
- Hard Copy

Patient Eligibility
Eligibility
- The patient has high suspicion of Sleep Apnoea and meets the Medicare requirements for a Medicare Subsidised Sleep Study. We will proceed to facilitate the Sleep study by a supervising Sleep Physician.
- Unfortunatelythe patient does not meet Medicare requirements for a Medicare Subsidised Sleep Study. We will arrange for a Sleep Physician consultation to determine the necessity for a Sleep Study for the patient.

Patient Details