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Spark Sleep Solutions
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    • Santa Cruz
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    • El Camino Hospital – Los Gatos
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Treatments

Visit us at one of our six locations!

  • San Jose
  • El Camino Hospital – Los Gatos Sleep Clinic
  • Los Gatos
  • San Ramon
  • Santa Cruz
  • Sunnyvale
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408.490.0182
408.624.4545
info@sparksleep.com
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Physician Referral Form

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









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

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.