PATIENT REFERRAL

Patient Name:

Phone:

Appointment Date & Time:

Please call (973) 567-7888 to schedule your patient's appointment.

Date of Sleep Study:

Diagnosis:

Obstructive Sleep Apenea

Insomnia due to Sleep Apenea

Hypersomnia due to Sleep Apenea

Sleep Apenea (other/unspecified)

Primary Snoring

Other:

Sleep Study Results without Appliance:

Respiratory Disturbance Index (RDI)

Apnea Hypopnea Index (AHI)

Lowest desaturation (SpO2)

Percentage of time below 90%

Sleep Study Results with Appliance:

Respiratory Disturbance Index (RDI)

Apnea Hypopnea Index (AHI)

Lowest desaturation (SpO2)

Percentage of time below 90%

Treatment Orders:

Mandibular Advancement Device for treatment of OSA

Mandibular Advancement Device to be used in combination with CPAP

Mandibular Advancement Device for treatment of Primary Snoring

Medical Justification for the Recommendation of a Mandicular Advancement Device:

Mild sleep apenea

Moderate sleep apenea

Unable to tolerate mask/strap

Unable to tolerate effective CPAP pressure

Skin sensitivity

Claustrophobia

Insufficient surgical outcome

Other:

Rx:

Statement of medical necessity: This patient has undergone a sleep study for a sleep related breathing disorder. This evaluation confirmed the diagnosis, and a Mandibular Advancement Device is medically necessary due to the justification(s) identified above.

Physician Name:

Phone:

Signature:

Medical License #:

NPI #:

PATIENT REFERRAL

PLEASE BRING THIS FROM TO YOUR APPOINTMENT.