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Recommendation for Oral Appliance Therapy

Please complete this form to provide your recommendations for oral appliance therapy. Accurate details help us ensure proper patient care and follow-up.

Recommendation Details

Please fill all fields for better evaluation.

Patient Name:

Date of birth:

Address:

City, State, Zip:

Telephone: (H)

Height:

Weight

Sleep Study Date:

AHI:

RDI:

CPAP Pressure:

Diagnosis (please check all that apply)

Obstructive Sleep ApneaUpper Airway Resistance SyndromeNarcolepsyPeriodic Limb Movement DisorderRestless Leg SyndromePrimary Snoring

Other:

Treatment Orders (please check all that apply)

Mandibular Advancement Device for treatment of OSAMandibular Advancement Device to be used in combination with CPAPMandibular Advancement Device for treatment of primary snoring

Other:

Medical Justification

Patient has tried CPAP and has not tolerated and/or complied with treatment for the followingreasons:

Unable to tolerate mask/strapsUnable to tolerate effective CPAP pressureSkin sensitivityClaustrophobiaOther Continuation of CareN/A

Due to the history and diagnosis above, I am recommending oral appliance therapy for the treatment of this patient. I, the undersigned, certify the procedure prescribed above is medically necessary for the treatment of this sleep disorder. I understand the oral appliance will be needed for an indefinite period of time.

Referring Physician:

Phone:

Signature:

Date:

NPI#:

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