Patient & Physician Forms

Print the following forms. Fill them out completely and bring them with you to your first visit. In order to view these forms you must have Adobe Acrobat Reader installed on your computer.


Dear Patient,

We want to take this opportunity to welcome you to our sleep center and thank you for choosing us to provide your health care. We appreciate your trust in us and look forward to keeping you healthy.

Please complete all the forms BEFORE your scheduled appointment and bring them along with your current insurance card(s), all medications (including inhalers, over-the-counter medications, herbs) and your CPAP or BiPAP machine (if you are using one). 

**Please note that your 7-day Sleep Log that must be completed prior to coming in for your scheduled appointment.

WE STRONGLY RECOMMEND that if you have any questions concerning your insurance coverage or co-pays please call your insurance company directly. If an authorization is needed you may have your referring physician fax us the authorization to Lansing fax at (517) 887-6736 or Brighton fax at (810) 225-7597 prior to your appointment.

You can reference the following codes:                    

Billing Codes: Polysomnography=95810   CPAP=95811
Diagnosis Code:   OSA=327.23       

If you need to reschedule your appointment, please call the location of your appointment either Lansing (517) 887-6733 or Brighton (810) 225-7595 as early as possible, but no later than 24 hours prior, or you will be subject to a late cancellation/missed appointment fee of $150.00 per sleep study or $25 per office consultation.

Sincerely,

Mid-West Center for Sleep Disorders


Patient Forms

© Copyright 2017, Mid-West Centers for Sleep Disorders. All Rights Reserved.
Web design by Dynamite Inc.