Secure Referral Portal - www.respirologist.com.au

REFERRAL FOR CONSULTATION OR INVESTIGATIONS

The electronic referral on this page is only for use by medical practitioners and other eligible referrers.

Please select the service required and complete the relevant further details.

Need to talk to us? We'd be happy to talk to you - please ring the rooms on 07 3123 5350 or email reception@respirologist.com.au.

As an alternative to using this page, you can download a PDF version of our referral pad (private referrals only). Note that a downloadable PDF of the completed electronic referral is generated after submission (for saving into your EMR).

Best Practice Referral Template

Medical Director Referral Template

Referral date*

I am a:*

Referral is for*

Important message!

From November 1 2018, Medicare has restricted direct referrals for sleep studies to those with an Epworth Score of 8 or more AND high risk on a validated questionnaire (OSA50, STOP-Bang or Berlin).

If your patient does not meet these criteria (more than 50% of patients with significant OSA will not meet these criteria), Medicare requires consultation with a respiratory/sleep physician first.

EPWORTH SLEEPINESS SCORE

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired?

This refers to your usual way of life in recent times.

Even if you haven’t done some of these things recently try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation:

0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing

It is important that you answer each question as best you can.

Sitting and reading*

0
1
2
3

Watching TV*

0
1
2
3

Sitting, inactive in a public place (e.g. a theatre or a meeting)*

0
1
2
3

As a passenger in a car for an hour without a break*

0
1
2
3

Lying down to rest in the afternoon when circumstances permit*

0
1
2
3

Sitting and talking to someone*

0
1
2
3

Sitting quietly after a lunch without alcohol*

0
1
2
3

In a car, while stopped for a few minutes in the traffic*

0
1
2
3

Epworth Score:

The patient's Epworth score is not high enough (<8) to be eligible for direct referral to a sleep study under Medicare. Please note that this does not mean that the patient does not have sleep apnoea or another sleep disorder. Please select sleep physician consultation from blue box drop down towards the top of the page.

Please complete the following questions.

Is waist circumference > 102 cm if male or > 88 cm if female?*

No
Yes

Is there a history of snoring?*

No
Yes

Is there a history of apnoeas?*

No
Yes

Is the patient > 50 years old?*

No
Yes

OSA50 Score:

The patient qualifies for a direct referral for a sleep study under Medicare - please continue to complete the demographic and referral details.

The patient's OSA50 score is not high enough (<5) to be eligible for direct referral to a sleep study under Medicare. Please note that this does not mean that the patient does not have sleep apnoea or another sleep disorder. Please select sleep physician consultation from the above drop down.

Do any of the following apply (please select "None" if none apply).*

Suspected obstructive sleep apnoea syndrome where the patient is assessed as not suitable for an unattended sleep study.
Suspected central sleep apnoea syndrome.
Suspected sleep hypoventilation syndrome.
Suspected sleep‑related breathing disorders in association with non‑respiratory co‑morbid conditions including heart failure, significant cardiac arrhythmias, neurological disease, acromegaly or hypothyroidism.
Suspected parasomnia or seizure disorder where clinical diagnosis cannot be established on clinical features alone (including associated atypical features, vigilance behaviours or failure to respond to conventional therapy).
Suspected sleep related movement disorder where the diagnosis of restless legs is not evident on clinical assessment.
Requires carer/assistance at night.
None of the above.

The above conditions may necessitate in-lab rather than home diagnostic study.

Test required:*

Spirometry, flow volume loops and exhaled nitric oxide (assessment of asthma)
Spirometry, flow volume loops and transfer factor (assessment of COPD, interstitial lung disease, dyspnoea of uncertain cause)
Cardiopulmonary exercise test
Indirect/mannitol bronchoprovocation test
High altitude simulation test
6 minute walk test for the purposes of medicare funded pulmonary hypertension therapy

(Under Medicare rules, only one of the above tests is permitted per day/referral)

Patient name*

First Last

Patient DOB*

Patient Gender*

Patient Mobile Tel

Patient Home Tel

Please include area code.

Clinical notes

Please include any further relevant clinical information here.

Referrer Name*

Referrer Provider Number:*

Referrer Telephone Number:*

Referrer Signature*

Result delivery preference*

Referrer fax number:

Address to send results to: