Clinician/Order CPAP Equipment

Sleep Medicine Referral Form & ICD-9 Codes for Diagnostic Services Patient Name DOB:
E-mail
Address
City State: Zip:
Home Ph #: Cell #: Wk Ph #:
Please attach related patient's clinical history, physician notes and demographics which include insurance information.
Referring Physician: NPI: UPIN: Address City State: Zip:
Symptoms & Reason for Referral Witnessed/Suspected Sleep Apnea Hypertension Snoring Obesity Diabetes Restless Leg Syndrome Excessive daytime Sleepiness Cardiac Disease Mood Disorder Morning Headaches COPD History of OSA (327.23) Stroke
Sleep Disorders Diagnostic Services Please initiate treatment if positive for OSA CPAP +/-2 cm H20 APAP +/-2 cm H20 Bi-Level +/-2 cm H20 Please provide patient with all necessary CPAP supplies (ex. mask, headgear, tubing, filters and/or humidifier) to assure compliance. Provide patient with a humidifier (cool or heated) Provide patient with a humidifier (cool or heated) increase to cm H2O decrease to cm H2O Provide patient with replacement CPAP supplies Discontinue CPAP treatment Special requests:
Physician Signature Date:

Clinician/Order CPAP Equipment

Sleep Data will prepare your patient’s equipment for delivery or pickup at one of our convenient locations.

Often, a telephone call or a fax is all that is necessary. If you choose to use the email order for ordering supplies for your patient provided above, please do so.  Otherwise Sleep Data has a fax referral and statement of medical necessity forms that you are welcome to utilize provided below.

If you are a physician and your office already utilizes a form or has chart notes on your patient, you are welcome to fax these forms. We simply need patient contact information and insurance information. Sleep Data will verify benefits and perform insurance authorization, if necessary. We’ll contact your patient and take it from there.

Download our  fax forms here:

Sleep Medicine Referral Form CPAP

Please note that the Certificate of Medical Necessity requires a clinician’s signature rather than a stamp.  A faxed version of a signature IS valid.

Medical Necessity Form

if you are an existing patient and you’d like to re-order supplies please click on the link below

Existing Patient CPAP Supplies Re-Order form

 (Forms are in PDF format, free Acrobat Reader required. Download here.)

Questions?
Call us at: 800.619.4672
Fax us at: 619.299.6222
or e-mail us at: mail@sleepdata.com