Little Neck Location: 49-33 Little Neck Parkway, Little Neck NY 11362
Phone: 718-229-0193   Fax: 718-229-3864
New York Location: 132 East 76th Street, Suite 2A, New York NY 10021
Phone: 917-750-5058
Patient's Information
Insurance Provider:
Sleep Study Available:
Reason For Referral (Mark all that apply)
Diagnosis, if any:
Sleep Study Data (if available) Without Appliance (CPAP or Oral Appliance):
Therapies Attempted:
Statement Of Medical Necessity

This above patient has undergone a sleep study for a sleep related breathing disorder and is being sent for fabrication of an oral appliance. This evaluation confirmed the diagnosis of obstructive sleep apnea and this serves as confirmation that an Oral Appliance is medically necessary. Oral Appliance Therapy is used as an alternative to surgery or CPAP at this time, as this patient could not tolerate CPAP or does not feel they will be able to tolerate CPAP.

Thank you for your referral. If you have any questions please contact Jenna at 844-44-SNORE or