CPAP/BIPAP Standard Written Order
Patient Information
Patient Name
*
First Name
Last Name
Today's Date
*
-
Month
-
Day
Year
Date
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Diagnosis
*
Back
Next
Order Information
Policy Number
*
Length of Need (Lifetime=99)
*
PAP Device
Select one of the following devices and indicate settings.
Cpap (E0601)
Auto Cpap (E0601)
Cpap Settings
*
Auto Cpap Settings
*
BIPAP Device
If Bipap is being ordered, has the Cpap ben tried and proven ineffective?
Yes
No
Select one of the following devices and indicate the settings.
Bipap (E0470)
Auto Bipap (E0470)
Bipap Auto ASV (E0471)
Bipap (E0470) Device Settings
*
Auto Bipap Device Settings
*
Bipap Auto ASV Device Settings
*
If the patient is currently receiving oxygen therapy, please complete :
Oxygen Bleed In (LPM)
Humidifier
Replacement (A07046) 1/6 Months
Tubing
Heated (A4604) 1/3 months
Standard 97037) 1/3 month
Filters
Disposable (A7038) 2/months
Non-Disposable (a7039) 1/6 month
Mask Options
Select Full, Nasal or Pillows (Patients Choice)
Full Face Mask
Mask (A7030) 1/3 months
Replacement Cushion (A7031) 2/months
Headgear (A7035) 1/6 months
Nasal Mask
Mask (A7034) 1/3 months
Replacement Cushion (A7032) 2/months
Headgear (A7035) 1/6 months
Nasal Pillows
Mask (A7034) 1/3 months
Replacement Pillows (A7033) 2 set/months
Headgear (A7035) 1/6 months
Documentation Checklist - REQUIRED
*
Patient Demographics
Oxygen Oximetry
Face-to-Face Visit Notes
Overnight Oximetry (Overnight Only)
Insurance Card
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back
Next
Provider Information
Provider Name
*
First Name
Last Name
NPI:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Fax Number
*
Please enter a valid fax number.
Format: (000) 000-0000.
Provider Signature
*
Today's Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: