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

Requesting Physician's Name:

Organization:

Phone:

Fax:

Patient's Name:

DOB (Date of Birth):

Patient's Contact Number:

Notes:

Diagnosis:
Obstructive Sleep Apnea - ICD G47.33Hypersomnia due to Sleep Apnea - ICD G47.10Sleep Apnea/Sleep Related Breathing Disorder, Unspecified - ICD G47.30 (UARS)Sleep Apnea, Other, Unspecified - ICD G47.30Temporomandibular Joint Dysfunction / Orofacial PainOther

Patient's Diagnostic Sleep Study Results (without CPAP or OA):

Date of Study:

Respiratory Disturbance Index (RDI):

Apnea Hyponea Index (AHI):

Lowest O2 Saturation (SpO2):

Statement of Medical Necessity

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

Physician's Signature:

Date:

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