tmj and sleep referral

Dr. Charles Ferzli

DABCP, DABCDSM, FAACP
1150 NW Maynard Road. #140 Cary, NC 27513

919.323.4242

919.462.3360

PATIENT INFORMATION

Last Name: First Name M.I.

Street Address

Apartment/Unit #:

City:

State:

Zip Code:

Home Phone:

DOB:

E‐mail:

Requesting Physician's Name:

E-mail:

Sleep Study Available:

Yes No

REASON FOR REFERRAL (MARK ALL THAT APPLY)

Diagnosis: Obstructive Sleep Apnea (ICD 327.23)

Sleep Apnea/Sleep Related Breathing Disorder, Unspecified (ICD 327.20)

Rx: Fabricate Custom Oral Appliance

Insomnia due to Sleep Apnea (ICD 780.51)

Other, Unspecified (ICD 780.57)

Hypersomnia due to Sleep Apnea (ICD 780.53)

Without Appliance (CPAP or Oral Appliance):

Respiratory Disturbance Index (RDI):

Lowest Desaturation (Sp02):

Apnea Hypopnea Index (AHI):

Percentage of Time Below 90%:

Therapies Attempted:

CPAP: Intolerant Not a good candidate

Surgery:

Yes No

Comments/ Special Concerns:

Please include a copy of the patients sleep study, an RX stating the patient is CPAP intolerant, and the patients demographic sheet.

STATEMENT OF MEDICAL NECESSITY

This above patient has undergone a sleep study for a sleep related breathing disorder. This evaluation confirmed that an Oral Appliance is medically necessary. Oral Appliance Therapy (OAT) is used as an alternative to surgery at this time and or CPAP, as this patient could not tolerate CPAP or does not feel he/she will be able to tolerate CPAP.

Physician's Signature:

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Date: