Provider Form

PRACTITIONER INFORMATION
Name*

First NameLast Name
Practice/Organization*
Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
NPI Number*
PATIENT INFORMATION
Patient Name*

First NameLast Name
Preferred Name
Date of Birth*

YearMonthDay
Date
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company
Member ID
Insurance State
This can be found on the back of your ID card.
Please select the age range of your patient.*

13-1718+
Adults (18+) with:*

Panic Disorder (including recurring panic attacks)PTSDOther (please provide reason for authorization; required)
Adolescents (13-17) with:*

Patient Reported Symptoms Associated with Stress and Anxiety (including trauma symptoms)Other (please provide reason for authorization; required)
Diagnosed Conditions*

Panic DisorderPTSDPanic Disorder and PTSDReoccurring panic attacks that impair their quality of lifeOther. Please tell us in notes, below
If they have a diagnosis other than PTSD or Panic, please provide explanation:
Optional: Authorize your patient for Freespira treatment
Upload Medical Records associated to the diagnosis

Panic or PTSD assessment
Cancelof
I understand that, with my signature, I am authorizing (prescribing) the Freespira treatment (capnography-guided respiratory Intervention), and I have informed the patient to expect outreach from a Freespira representative for enrollment into treatment.

I am not aware of any contraindications or other reasons why the patient identified above should not, at this time, undergo the Freespira treatment. I agree that this signature may also be applied to a Certificate of Medical Necessity.
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example@example.com
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