Physician Referral Form Form

Little Neck Location: 49-33 Little Neck Parkway, Little Neck NY 11362

Phone: 718-229-0193 Fax: 718-229-3864

New York Location: 160 Middle Neck Road, Suite 1, Great Neck NY 11021

Phone: 516-773-4133

Patient's Information

Full Name:

Birthday:

Address (Street):

City:

State:

Zip:

Home Phone:

Email:

Requesting Physician's Name:

Physician's Email:

Insurance Provider:

HMO

PPO

POS

EPO

Indem

MCR

MCD

Policy Number:

Group Number:

Employer:

Insured:

Self

Spouse

Child

Other

Sleep Study Available:

Yes

Medicare:

Yes

Reason For Referral (Mark all that apply)

Diagnosis, if any:

Obstructive Sleep Apnea (ICD 327.23)

Insomnia due to Sleep Apnea (ICD 780.51)

Sleep Apnea/Sleep Related Breathing Disorder, Unspecified (ICD 327.20)

Hypersomnia due to Sleep Apnea (ICD 780.53)

Other, Unspecified (ICD 780.57)

Sleep Study Data (if available) Without Appliance (CPAP or Oral Appliance):

Respiratory Disturbance Index (RDI):

Lowest Desaturation (SpO2):

ODI:

Apnea Hypopnea Index (AHI):

Percentage or Amount of Time Below 90%:

Therapies Attempted:

CPAP:

Intolerant

Not A Good Candidate

Surgery:

Yes

Other:

Successful CPAP Pressure:

Comments/Special Concerns:

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.

Physician's Signature:

Date:

NPI:

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

Patient Validation:

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