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2018-01-26T09:46:31-05:00
2018-01-26T09:46:31-05:00
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PATIENT INFORMATION
PATIENT INFORMATION
REASON FOR REFERRAL (MARK ALL THAT APPLY)
REASON FOR REFERRAL (MARK ALL THAT APPLY)
Full Name: Address:
Full Name: Address:
Last First M.I.
Last First M.I.
Street Address Apartment/Unit #
Street Address Apartment/Unit #
City State Zip Code
City State Zip Code
Diagnosis: Obstructive Sleep Apnea (ICD 327.23)
Diagnosis: Obstructive Sleep Apnea (ICD 327.23) Insomnia due to Sleep Apnea (ICD 780.51) Sleep Apnea/Sleep Related Breathing Disorder, Unspecified (ICD327.20)
Without Appliance (CPAP or Oral Appliance):
Without Appliance (CPAP or Oral Appliance):
STATEMENT OF MEDICAL NECESSITY
STATEMENT OF MEDICAL NECESSITY
Please include a copy of the patients sleep study, an RX statin
Please include a copy of the patients sleep study, an RX stating the patient is CPAP intolerant, and the patients demographic sheet.
Therapies Attempted:
Therapies Attempted:
Rx: Fabricate Custom Oral Appliance
Rx: Fabricate Custom Oral Appliance
Hypersomnia due to Sleep Apnea (ICD 780.53)
Hypersomnia due to Sleep Apnea (ICD 780.53)
Home Phone: ( )
Home Phone: ( )
Requesting Physician’s Name:
Requesting Physician’s Name:
Insurance Provider: HMO PPO POS EPO
Insurance Provider: HMO PPO POS EPO INDEM MCR MCD
Policy Number: Group Number: Employer:
Policy Number: Group Number: Employer:
Insured: Self Child Other
Insured: Self Child Other
Sleep Study Available: YES NO
Sleep Study Available: YES NO
Medicare: YES NO
Medicare: YES NO
DOB:
DOB:
Email:
Email:
Email:
Email:
Other, Unspecified (ICD 780.57)
Other, Unspecified (ICD 780.57)
Physician’s Signature: Date:
Physician’s Signature: Date:
This above patient has undergone a sleep study for a sleep rela
This above patient has undergone a sleep study for a sleep related breathing disorder. This evaluation confirmed that an Oral Appliance is medically necessary. Oral Appliance Therapy (OAT) is used as an alternative to surgery at this time and or CPAP, as this patient could not tolerate CPAP or does not feel he/she will be able to tolerate CPAP.
Respiratory Disturbance Index (RDI) Lowest Desatura
Respiratory Disturbance Index (RDI) Lowest Desaturation (SpO2) Apnea Hypopnea Index (AHI) Percentage of Time Below 90%
Comments/ Special Concerns:
Comments/ Special Concerns:
CPAP: Intolerant Not a good candidate
CPAP: Intolerant Not a good candidate
Surgery: YES NO
Surgery: YES NO
Dr. Alan Wasserman 22053 State Road 7 Boca Raton, FL 33428 Ph
Dr. Alan Wasserman 22053 State Road 7 Boca Raton, FL 33428 Phone: 561.203.1352 Fax: 561.482.5005
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