Order for home CPAP
Patient Name
*
First Name
Last Name
Patient Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Referring Physician
*
Sahil Chopra (NPI: 1245545326 )
CPAP
New order for CPAP
Discontinue order for CPAP
Please Select equipment and supplies
Certification Type
*
Initial
Renewal
Type of Device
*
APAP (E0601) 1 every 5 years
BiLevel (E0470) 1 every 5 years
BiLevel with back-up rate (E0471) 1 every 5 years
Tubing with Heated Element (A4604)
Diagnosis
Patient Prognosis
Good
Fair
Poor
Diagnosis
*
OSA (G47.33)
Complex sleep apnea (G47.37)
Central sleep apnea (G47.37)
Secondary Diagnosis (If OSA and AHI is 5-14/hr)
Excessive daytime sleepiness
Insomnia
Mood Disorder
Ischemic Heart Disease
Stroke
Hypertension
Arrhythmia
Most recent HST was on:
blanks
*
The AHI was:
blank
*
Settings for Device:
*
Please upload recent home sleep test
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Please upload MD documentation
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MD Signature
*
Submit
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