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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 of OSAHS defined by 15 or more obstructive respiratory events per hour of sleep? Yes No Was the diagnosis of OSAHS defined by 5 provigil yeast infections modafinilo 100 mg nombre comercial provigil schedule class provigil goodrx 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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