MD Rx for Oral appliance therapy
Patient Name
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First Name
Last Name
Patient Email (we will send them a copy as well)
example@example.com
Patients Date of Birth
*
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Month
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Day
Year
Date
Patient presented to my office for sleep and/or breathing disorder consultation with the chief complaint of:
Excessive daytime sleepiness
Chronic Fatigue
Snoring
Bruxism
Mouth breathing
Headaches
Observed apnea
Trouble concentrating
Other
I am requesting your permission to prescribe OAT (oral appliance therapy) to treat:
Snoring (R06.83)
Obstructive sleep apnea (G 47.33)
Maxillary hypoplasia (M26.02)
Maxilla Retrognathia (M26.01)
Mandible Retrognathia
Mandible Asymmetry
Dentofacial functional abnormalities
Other
Date of sleep test
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Month
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Day
Year
Date
Patient obstructive sleep apnea is
Mild
Moderate
Severe
AHI 3% is:
AHI 4% is:
RDI is:
ODI 3% is:
Upload interpreted sleep test
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Please upload a copy of the Affidavit for intolerance or Non-compliance to CPAP
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Prescription is for :
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Sleep Apnea Appliance: E0486
Oral Appliance therapy: 21299
Oral device/appliance for upper airway collapsibility (without fixed mechanical hinge, custom fabricated): K1027
Other
Doctor Name
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First Name
Last Name
Doctors email
example@example.com
Dental office phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Requesting doctors Signature
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