Referring Providers

New Patient Referral Form

Patient Information

Name

Date of Birth

Gender

Height

Weight (lbs)

Social Security Number

Home Address

Medical History

Please provide the following documentation in .pdf, .doc, or .docx format

Medical Insurance Info

Face-to-face chart notes

Baseline Sleep Study (CPAP titration & pulse oximetry tests do not qualify)

Chart Notes Discussing Sleep Apnea or CPAP Intolerance (within 6 months to a year)

Physician Information

Name

NPI

Phone

Fax

Patient is being referred to Luke Bauserman, DDC, CCSH, DIAOS for evaluation and fitting of amedically necessary oral sleep appliance (E0486/K1027) as indicated.

Items Ordered: E0486/K1027 Custom-fabricated oral appliance for OSA.
Diagnosis/IC 10: G47.33 Obstructive Sleep Apnea
Length of Need: Lifetime

Physician's Confirmation

Today's Date

Additional Information

Potential Patients

If you’re ready to get the restful sleep you deserve, it’s time to speak to one of our sleep professionals. Our team will work with you to create a personalized treatment plan that fits your specific needs. If you’re still unsure, take our short sleep quiz that identifies the most common sleep-related issues to see which ones you’ve experienced.