Dme Online Form
User Manual: Pdf dme-online-form
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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:____________________
Humidifier(s) O Patient Preference Heated Humidifier (E0562)
O Passover Humidifier (E0561) O Heated Humidifier (E0562)
CPAP Mask/Interface/Delivery System:
O CPAP Mask, Patient Preference
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)
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
Prescription /Letter of Medical Necessity
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) Headgear (A7035) Oral Interface (A7044)
Full Face Cushion (A7031) Chinstrap (A7036) Exhalation Port/Swivel (A7045)
Nasal Mask (A7034) Tubing (A7037) Humidifier Chamber (A7046)
Mask Cushion (A7032) Disposable Filters (A7038) Non-Disposable Filters (A7039)
Nasal Pillows (A7033) Heated Humidifier Tubing w/ Heating Element (A4604)
Physician's Signature: ___________________________________________ NPI:__________________________________
Date:__________________________ 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.
___Overnight Sleep Study ___Referral to Primary Care Physician
___Referral to Board Certified Sleep Physician ___No Indication (6 month re-evaluation)
Dr. Signature:________________________________
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 ?
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:________________________________
Circle all that apply:
High Blood Pressure Heart Disease Diabetes
Restless Leg Syndrome Sleep Apnea Insomnia
Narcolepsy Depression Anxiety /PTSD
Recent Head Trauma Stroke Neurological Disorder
Pain Condition A.M. Headaches Night Sweats
Sleep: (Circle One)
Have you been told that you stop breathing while asleep? YES NO
Have you ever fallen asleep or nodded off while driving? YES NO
Do you awaken suddenly with shortness of breath, gasping or with your heart racing? YES NO
Do you feel excessively tired during the day? YES NO
Has anyone ever told you that you snore while you are sleeping? YES NO
Do you feel burning, tingling, or crawling sensations in your legs while you are awake? YES NO
Insomnia: (Circle One)
Difficulty falling asleep None Mild Moderate Severe Very Severe
Difficulty staying asleep None Mild Moderate Severe Very Severe
Problem waking up too early None Mild Moderate 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? YES NO
Do you elevated cholesterol or triglycerides? YES NO
Do you have varicose veins? YES NO
Do you ever stand up and get light headed? YES NO
Do you have erectile dysfunction? (men) YES NO
Do you have heart palpitations or heart “flutters”? YES NO
Have you ever had a sudden loss of vision in one eye, usually lasting only seconds? YES NO
Do you have, or easily get, cold hands or feet? YES NO
Do you have gum disease, gingivitis, or periodontitis? YES NO
When walking or exercising, do you get leg pain or cramping? YES NO
Weight Loss:(Circle One)
Is your BMI over 39? YES NO
Do you feel tired during the day? YES NO
How many times per week do you exercise? _____________________
Do you need to lose 20lbs more? YES NO
Have you had weight gain and found it difficult to lose? YES NO
Name:_________________________ D.O.B.____________AGE:___________
Insurance:________________ Phone:_______________ Ht:______ Wt:______
Patient Signature_________________________ Date:_____________________
Sleep Questionnaire
Weight Loss Sign - In
Name: Time - In: Time - Out: Signature: Date:
