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FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED Obstructive sleep apnea/hypopnea syndrome (OSAHS): Has the diagnosis of OSAHS been confirmed by a sleep study? Yes No If a sleep study has not been completed, please provide justification confirming why a sleep study would not be feasible: __________________________________________________________________________________________________________ Was the diagnosis provigil of OSAHS defined by 15 or more obstructive respiratory events per hour of sleep? Yes No Was the diagnosis of OSAHS defined by 5 or more obstructive respiratory events per hour of sleep AND one of these symptoms (unintentional sleep episodes during wakefulness, daytime sleepiness, unrefreshing sleep, fatigue, insomnia, waking up breath holding/gasping/choking, loud snoring or breathing interruptions during sleep)? Yes No Reauthorization: If this is a reauthorization request, answer the following question: Is there documentation of positive clinical response to prior therapy? Yes No Shift work sleep disorder (SWSD): Has SWSD been confirmed by one of the following (select from the two options below)? Symptoms of excessive sleepiness or insomnia, for at least 3 months, which is associated with a work period (usually night work) that occurs during the normal sleep period .
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