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Certificate of Medical Necessity

Location:
 
Patient Information:
  
Insurance Information (Send Copy of Card)
Patient Name:

 
Company Name:
Address:

 
Policy Holder Name:
City:

 
Policy Number:
State:
Zip Code:
 
Group Number:
D.O.B.:

 
Phone:
Social Security #:
 
Employer:
Phone:

     
Alt. Phone:
      
Measurements:

     
Neck Size      
Prescription Information:
      
Sleep Study Diagnostic
Sleep Study with CPAP Titration
Sleep Study for Re-Evaluation
MSLT
Statement of Necessity - Symptomology
      
Loud Snoring
Severe Mood Swings
Headaches In Morning
Witnessed Apnea
Decreased Concentration
Depression
Daytime Somnolence
Frequent Use of Bathroom at Night
High Blood Pressure
Obesity
Doze Off While Driving
Weight Gain
Leg Kicking/Jerking During Sleep
Sweat Excessively
Irregular Heartbeat
Never Feel Rested
Wake Up Coughing/Gagging
Other
Diagnosis - Reason for Study
  
Medical Director Approval:
Sleep Apnea
Obstructive Sleep Apnea - Titrate CPAP
Obstructive Sleep Apnea - Re-Evaluate To Determine If Current CPAP Level Is Appropriate
Obesity:
 
Due to the above symptomology and diagnosis. I, the undersigned, certify that the prescribed procedure is reasonable and necessary according to the standards of medical practice in the treatment of this condition.
Physician Signature:
Date:
Printed Name:
NPI#:
Address:
Phone#:
City:
Fax#:
State:
   
Zip Code:
   
         

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Our Sleep Centers:
The Sleep Disorders Institute of Chandler
70 North McClintock Drive
Suite 4
Chandler, AZ 85266
480-785-0564
480-753-4709 Fax
877-427-0870 Toll Free
info@sleeppd.com
The Sleep Disorders Center of Perrysburg
1090 W. South Boundary St. Suite 300
Perrysburg, OH 43551
877-427-0870 Toll Free
419-872-3660
419-872-3662 Fax
info@sleeppd.com
DME
866-427-0099 Toll Free
419-872-3662 Fax
dme@sleeppd.com
The Sleep Disorders Center of Lambertville
3608 Sterns Rd.
Lambertville, MI 48144
734-568-6068
734-568-6069 Fax
877-427-0870 Toll Free
info@sleeppd.com
Hardin Memorial Hospital Sleep Center
921 E. Franklin St.
Kenton, OH 43326
877-427-0870
St. Francis Hospital Sleep Center
401 N. Broadway
Green Springs, OH 44836
877-427-0870