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Prescription /Letter of Medical Necessity Ordering Physician ________________________________________________ Physician's Address________________________________________________ Phone ______________________Fax:_______________________________ Supplier : Americansleepcenters.com * 9439 W Archibald ave. #105 Rancho Cucamonga, CA 91730 Supplier Information Fax 1-888-553-3077 * 909-987-5510 CA License 56879TX Tax ID 203626682 Date:____________________ Diagnosis ICD-10: O G47.33 Obstructive Sleep Apnea (OSA) (Adult and Child) O Other ______________________________ O Secondary condition (if AHI/RDI is 5–14) __________________________ Estimated length of need _______ months (99 = lifetime) E1390 Oxygen; bleed in at _______ LPM Humidifier(s) O Patient Preference Heated Humidifier (E0562) O Passover Humidifier (E0561) CPAP Mask/Interface/Delivery System: O CPAP Mask, Patient Preference O Heated Humidifier (E0562) Select ONE only: E0601 CPAP _____ cmH2O (4–20 cmH2O) Ramp time _____ min(s) (OFF–45 min) OR Check box to adjust to patient comfort E0601 Auto Adjusting CPAP with settings of 4–20 cmH2O with comfort settings E0601 Auto Adjusting CPAP with settings of _____ cmH2O to _____ cmH2O with comfort settings (4–20 cmH2O) E0470 Bi-level IPAP _____ cmH2O (*4–25 cmH2O) EPAP _____ cmH2O (*4–25 cmH2O) E0470 Auto Adjusting Bi-level Max IPAP 25 cmH2O; Min EPAP 4 cmH2O; PS 4 cmH2O E0470 Auto Adjusting Bi-level Max IPAP ________cmH20 Min EPAP ___________cmH20 PS_______(0-10cmH20) The following dispensable equipment is necessary for the proper use of the equipment and is not a part of the CPAP, BiLevel, BiLevel ST, BiLevel SV or AVAPs machine when purchased and needs to be replaced on a regular basis: Full Face Mask (A7030) Full Face Cushion (A7031) Nasal Mask (A7034) Mask Cushion (A7032) Nasal Pillows (A7033) Headgear (A7035) Oral Interface (A7044) Chinstrap (A7036) Exhalation Port/Swivel (A7045) Tubing (A7037) Humidifier Chamber (A7046) Disposable Filters (A7038) Non-Disposable Filters (A7039) Heated Humidifier Tubing w/ Heating Element (A4604) Physician's Signature: ___________________________________________ Date:__________________________ NPI:__________________________________ License:_____________ __________________ Please fax to: 1-888-553-3077 O I would like free educational material sent to my office regarding Sleep Apnea and CPAP for my patients O Do not fax me further prescription requests on behalf of patients. Opt out fax: 1-888-553-3077 Sleep Questionnaire Dear Patient, Your Doctor is screening for sleep apnea with the below questionnaire and may recommend you for a sleep study. If you are recommended for a sleep study by your Doctor, the Sleep Lab will contact you directly to schedule your study and verify your insurance. Thank you. lose ? Sleep Questionnaire Dear Patient, Your Dentist is screening for sleep apnea with the below questionnaire and may recommend you for a sleep study. If you are recommended for a sleep study by your Dentist, the Sleep Lab will contact you directly to schedule your study and verify your insurance. This questionnaire was developed based upon the published findings of the American Academy of Sleep Medicine (AASM). The purpose of this questionnaire is to aid a qualified medical professional in identifying possible symptoms of a sleep disorder. This questionnaire is not meant to be used as a substitute for any diagnostic procedure. Check all that apply ___Enlarged/Scalloped Tongue ___Gastroesophageal Reflux ___Hypertension ___Heart Failure ___Retruded Lower Jaw ___Enlarged Tonsils ___Atrial Fibrillation ___Stroke ___High Arching Hard Palate ___Metabolic Syndrome ___Diabetes ___Bruxism lose ? ___Overnight Sleep Study ___Referral to Board Certified Sleep Physician ___Referral to Primary Care Physician ___No Indication (6 month re-evaluation) Dr. Signature:________________________________ Sleep Questionnaire Ph: 866.987.1611 Fax: 909.987.5510 Dear Patient, Your Dentist is screening for sleep apnea with the below questionnaire and may recommend you for a sleep study. If you are recommended for a sleep study by your Dentist, the Sleep Lab will contact you directly to schedule your study and verify your insurance. This questionnaire was developed based upon the published findings of the American Academy of Sleep Medicine (AASM). The purpose of this questionnaire is to aid a qualified medical professional in identifying possible symptoms of a sleep disorder. Check all that apply ___Enlarged/Scalloped Tongue ___Gastroesophageal Reflux ___Hypertension ___Heart Failure ___Retruded Lower Jaw ___Enlarged Tonsils ___Atrial Fibrillation ___Stroke ___High Arching Hard Palate ___Metabolic Syndrome ___Diabetes ___Bruxism lose? I would like to have someone contact me for a Home Sleep Study for a possible Oral Appliance Therapy. ___Overnight Sleep Study ___HST ___Referral to Primary Care Physician ___Referral to Board Certified Sleep Physician ___No Indication (6 month re-evaluation) Dentist Signature:________________________________ Sleep Questionnaire Name:_________________________ D.O.B.____________AGE:___________ Insurance:________________ Phone:_______________ Ht:______ Wt:______ Circle all that apply: High Blood Pressure Restless Leg Syndrome Narcolepsy Recent Head Trauma Pain Condition Heart Disease Sleep Apnea Depression Stroke A.M. Headaches Diabetes Insomnia Anxiety /PTSD Neurological Disorder Night Sweats Sleep: (Circle One) Have you been told that you stop breathing while asleep? Have you ever fallen asleep or nodded off while driving? Do you awaken suddenly with shortness of breath, gasping or with your heart racing? Do you feel excessively tired during the day? Has anyone ever told you that you snore while you are sleeping? Do you feel burning, tingling, or crawling sensations in your legs while you are awake? YES YES YES YES YES YES NO NO NO NO NO NO Insomnia: (Circle One) Difficulty falling asleep Difficulty staying asleep Problem waking up too early None None None Mild Mild Mild Moderate Moderate Moderate Severe Severe Severe Very Severe Very Severe Very Severe Do you have vivid or troubling nightmares? Never Rarely Sometimes Frequently Almost Always How often do you take a prescription medication to help you fall sleep or stay asleep? Never Rarely Sometimes Frequently Almost Always How often do you take an ‘Over the Counter’ medication to help you fall asleep or stay asleep? Never Rarely Sometimes Frequently Almost Always Cardiac: (Circle One) Do you smoke? Do you elevated cholesterol or triglycerides? Do you have varicose veins? Do you ever stand up and get light headed? Do you have erectile dysfunction? (men) Do you have heart palpitations or heart “flutters”? Have you ever had a sudden loss of vision in one eye, usually lasting only seconds? Do you have, or easily get, cold hands or feet? Do you have gum disease, gingivitis, or periodontitis? When walking or exercising, do you get leg pain or cramping? YES YES YES YES YES YES YES YES YES YES NO NO NO NO NO NO NO NO NO NO YES YES NO NO YES YES NO NO Weight Loss:(Circle One) Is your BMI over 39? Do you feel tired during the day? How many times per week do you exercise? _____________________ Do you need to lose 20lbs more? Have you had weight gain and found it difficult to lose? Patient Signature_________________________ Date:_____________________ Weight Loss Sign - In Date: Name: Time - In: Time - Out: Signature:
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