Patient Form Test - North Florida Sleep Resources

Patient Name

Date of Birth

Patient Phone

I am prescribing a Mandibular Advancement Device (E0486 or K1027) for the above-named patient who has been diagnosed with Obstructive Sleep Apnea (G47.33).

Severity:

MildModerateSevere

Patient declined CPAP or is CPAP intolerant:

YesNo

Patient has one of the following Comorbidities:

HypertensionExcessive Daytime SleepinessInsomniaMood DisorderImpaired CognitionIschemic Heart DiseaseHistory of stroke

I concur that the recommended therapy is medically necessary, and I now prescribe treatment, utilizing an FDA approved Mandibular Advancement Device. Length of need is lifetime. I strongly urge you to cover the costs of this therapy. Failure to do so would place the patient’s health in jeopardy.

Physicians Name

Physicians NPI

Physicians Signature

Patient Demographics:

Insurance:

Appointment Notes:

Sleep Study:

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