Clone of Home Sleep Study Order Form

DME PAP/Supply ORDER
PATIENT INFORMATION
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Sex*
Phone Number:*
E-mail
Patient will receive confirmation email with appointment details
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company
Insurance Policy #
Please Upload Insurance Card Image if possible

Cancelof
REFERRING PROVIDER INFORMATION
Provider Name*
Provider NPI Number*
Provider Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Office Phone *
Please enter a valid phone number.
Office Fax*
Please enter a valid fax number.
Provider Email
Please provide an email if you wish to receive confirmation that this referral has been successfully submitted to Athens Pulmonary & Sleep Medicine.
DIAGNOSIS

(G47.33 - Obstructive Sleep Apnea)
In addition to diagnosis code G47.33 (Obstructive Sleep Apnea), please indicate any additional diagnosis codes that may apply
Other Diagnosis Codes
If order a PAP Device (CPAP, APAP, BIPAP, etc...) Please select the "PAP Device" option and provide specifics, including device settings in the field provided.
Indicate All Supplies included with this order:*

Nasal Mask System (A7034)Nasal Mask Cushion (A7032)Headgear (A7035)Full Face Mask System (A7030)Full Face Mask Cushion (A7031)Headgear (A7035)Disposable Filters (A7038)Non-Disposable Filters (A7039)Water Chamber (A7046)Heated Tubing (A4604)Tubing (A7037)PAP DEVICE
Length of Need

99 months/lifetime
Orders for CPAP Supplies are valide for 1 year from issuance. New orders must be obtained annually per insurance coverage guidelines.

This order form constitutes an order for PAP Device/Supplies.
Ordering Provider Statement

I am requesting PAP device/supplies for this patient. I certify that, to the best of my ability, I have accurately answered all questions on this order form and submit this order form as an executable order for procurement of PAP device/supplies.
Signature*
Please type your name above as your electronic signautre.
DISCLAIMER: By typing your name above, you are signing this Order electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this order form.
Should be Empty:

PATIENT INFORMATION

REFERRING PROVIDER INFORMATION

DIAGNOSIS

Length of Need