CPAP PRESCRIPTION FORM

SUMMIT BEHAVIORAL HEALTH

CPAP PRESCRIPTION / LETTER OF MEDICAL NECESSITY
Patient Name *

First Name Last Name
Date of Birth

Month Day Year
Date
ORDERING PHYSICIAN CONTACT INFORMATION
NAME OF PROVIDER:

Dr. PIYUSH DAS

NPI: 1265639140

ADDRESS:

2115 COUNTY RD D EAST, STE C100

MAPLEWOOD, MN 55109

PH: 651-358-7020

FAX: 651-846-9890

EMAIL: ADMIN@SUMMITBHP.COM
DIAGNOSIS

327.23 OBSTRUCTIVE SLEEP APNEA 327.27 CENTRAL SLEEP APNEA 780.57 UNSPECIFIED SLEEP APNEA
PAP EQUIPMENT AND SUPPLIES

MACHINE TYPE AND CORRESPONDING PRESSURE
CPAP (E0601)
BIPAP / BI-LEVEL / VPAP (E0470)

IPAP EPAP
BIPAP / BI-LEVEL / VPAP- ST/SV (E0471)

IPAP EPAP
OTHER SUPPLIES
MASK AND OTHER NECESSARY SUPPLIES (LIST BELOW)
OTHER PRODUCTS
HEATED HUMIDIFIER (E0562)

SUPPLIES NECESSARY FOR THE PROPER USE OF PAP EQUIPMENT

FULL FACE MASK (A7030)	HEADGEAR (A7035)	ORAL INTERFACE (A7044)
FULL FACE CUSHION (A7031)	CHINSTRAP (A7036)	EXHALATION PORT/SWIVEL (A7045)
NASAL MASK (A7034)	TUBING (A7037)	HUMIDIFIER CHAMBER(A7046)
MASK CUSHION (A7032)	DISPOSABLE FILTER (A7038)	NON-DISPOSABLE FILTER (A7039)
NASAL PILLOW (A7033)	HEATED HUMIDIFIER TUBING WITH HEATED ELEMENT (A4604)

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SUMMIT BEHAVIORAL HEALTH