New Patient Forms - Sleep Apnea

Please correct the errors described below.

Patient Information

Emergency Contacts

Add Additional Emergency Contact

Financial Information

If "Someone Else" please fill out the information below:

Insurance Policy Information

If "Yes" please enter your policy information below, beginning with your Primary Insurance Policy.

Primary Insurance Policy

Add Additional Insurance Policy Information

Additional Information

Please list your preferred pharmacies in order of preference.

Add Additional Pharmacy Information

Medical History

Please check all that apply.

If "Yes" please list all of your allergies to medicine(s).

Add Medication Allergy

If "Yes" please list any current medications you are taking.

Add Additional Medication

Please list your healthcare providers, beginning with your primary care physician.

Add Additional Healthcare Provider

Surgical History

Dental History

Sleep Apnea History

If you answered "Yes" and have had multiple studies, list the most recent one without a CPAP

Add Surgical Procedure

We believe that sleep quality is a very important issue and often requires team approach. We will work closely with your sleep doctor and/or Primary care doctor. Are there any other health/wellness providers that you would like us to share your treatment progress with?

Add Health/Wellness provider

Epworth Sleepiness Scale

This questionnaire was developed to determine the level of daytime sleepiness in individuals. It has become one of the most frequently used methods for determining a person’s average level of daytime sleepiness. Please rate how likely you are to doze or fall asleep in the following situations by selecting the response that best applies. If you have not done some of these activities recently, select what would most likely happen if you were in that situation. Use the following scale to choose the most appropriate number for each situation:

  • 0 = would NEVER doze
  • 1 = SLIGHT CHANCE of dozing
  • 2 = MODERATE CHANCE of dozing
  • 3 = HIGH CHANCE of dozing

It is important that you answer each question as best you can.

Please add together the total number from your responses above and enter total here.

Medicare rules state if a patient's Medicare has been billed for a CPAP, BIPAP, or an oral appliance within the last 5 years, the patient may be denied benefits for an oral appliance. Based upon the Same and Similar Medicare guidelines please complete the following:

I understand if I answered Yes to the above questions, I am required to obtain from my physician the following:

  • Medical notes clearly indicating a change in my condition warranting a new piece of equipment.
  • Why CPAP or BIPAP is no longer sufficient.

By answering No to the above questions, I understand if my Medicare has for CPAP, BIPAP, oral appliance I may be responsible for my new appliance based upon the Same and Similar guidelines laid out by Medicare.

Acknowledgement of Receipt of Statement of Privacy Practices

Additional Disclosure Authorization

Authorization of Release

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