URLThis field is for validation purposes and should be left unchanged.Patient Name*Date of Birth MM slash DD slash YYYY Date of PSG or HST: MM slash DD slash YYYY AHI/RDI:The patient referred has been evaluated by the physician listed below and has been diagnosed with the following: Primary Snoring (R06.83) Obstructive Sleep Apnea (G47.33) Other This patient: Is intolerant to positive airway pressure (PAP) treatment. Is not a candidate for positive airway pressure (PAP) treatment Has decided, after all options have been discussed, they would like to proceed with oral appliance therapy as their initial treatment. Requires combination treatment of an oral appliance and CPAP therapy. Other SignatureI have attached Patient’s Demographics Copy of Patient’s Sleep Study Patient’s Insurance Information FileMax. file size: 256 MB.
