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
Patient obstructive sleep apnea is
Mild
Moderate
Severe
AHI 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
Other
Other
Doctor Name
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Last Name
Doctors email
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Dental office phone number
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Requesting doctors Signature
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