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Referral Form

Select a date

First Name

Last Name

Birthday

SSN#

Home #

Cell #

Work #

Address

PCP Name:

Referring Provider Name:

Phone #

Phone #

Primary Insurance:

Policy #

Group #

Secondary Insurance:

Policy #

Group #

Reason For Referral:

Lung Nodule

Obstructive Sleep Apnea (OSA)

Pulmonary Embolism

Astma

Chronic Obstructive Pulmonary Disease (COPD)

Pulmonary Hypertension

Interstitial Lung Disease (ILD)

Other:

Services Requested:

Pulmonary Consult

Pulmonary Function Test

Nocturnal Oximetry Test

Sleep Study: (A sleep consult by a CPI provider is required prior to conducting the sleep study)

In-Lab Diagnostic Study

In-Lab Split Study

In-Lab Titration Study

Home Sleep Test (HST)

Unsure/Most Appropriate

**If ordering a sleep study, please provide the following information/records with the referral:

Most recent progress note
Any previous sleep studies
If currently on PAP therapy, their most recent compliance report (last 30 - 60 days)

Name of Person Completing Form:

Contact Number:

Contact Email: *

THANK YOU FOR YOUR REFERRAL. OUR INTAKE COORDINATOR WILL REACH OUT TO THE PATIENT IN THE NEXT 24 - 48 hours.

15 West Dry Creek Circle

Littleton, CO 80120

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Sunday Closed

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