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// TECHYSCOUTS

Physician Referral Form

Oral Appliance Therapy Rx & Medical Necessity Form for Medically Diagnosed Obstructive Sleep Apnea





Patient's Name:




Diagnosis:
Patient has Diagnostic Sleep Study (without CPAP or OA):

Statement of Medical Necessity

I am referring the above patient to Dr. Srujal Shah, DDS, DABDSM because I believe it is Medically Necessary for him/her to be fitted for a custom fitted oral appliance (E0486).

The above patient had undergone a sleep study and has been diagnosed with obstructive sleep apnea (OSA). According to the American Academy of Sleep Medicine guidelines, oral appliance therapy is a treatment option for OSA. If a CPAP intolerance adavit is attached, it is because this patient could not tolerate CPAP.