REFERRING PHYSICIAN

Written prescription order for a custom, titratable oral appliance – See Below

A copy of the most recent sleep test (PSG/ HST)

Information needed for Obstructive Sleep Apnea Cases:

Medical Insurance information (optional and if available)

Written prescription order for a custom, titratable oral appliance (see Forms)

Copy of the Baseline Sleep Study & most recent PSG/ HST

Copy of the Medical chart notes prior to PSG/ HST & most recent notes discussing sleep issues

Letter of Medical Necessity

CPAP Intolerance Form (see Forms)

Copy of CAPAP stop Order Form (sent to DME company to stop supplies)