FORMS LIBRARY

CLINICAL DOCUMENTATION NEEDED FOR PRE-AUTHORIZATION, GAP EXCEPTIONS & CLAIMS

	New (as of 03/18/2022) – Sleep Apnea (OSA) Documentation Checklist Use this form as a checklist for all patients who need treatment for OSA.
	21085, 21110, D7880-Documentation-Checklist Use this form as a checklist for all patients who need treatment for 21085, 21110, D7880-Documentation-Checklist.
	Epworth Sleepiness Scale Include a copy of this form in each patient chart who has a diagnosis of Obstructive Sleep Apnea.
	Affidavit for Intolerance to CPAP Device Include a copy of this form in each patient chart who has a diagnosis of Obstructive Sleep Apnea.
	Dental Questionnaire Include a copy of this form in each patient chart who has a diagnosis of Obstructive Sleep Apnea.
	Member Authorization for a Designated Representative to Appeal a Determination Include a copy of this form in each patient chart.
	CPAP information from Referring Provider Include a copy of this form in each patient chart who has a diagnosis of Obstructive Sleep Apnea.
	Proof of Delivery Form Include a copy of this form in each patient chart who has a diagnosis of Obstructive Sleep Apnea.
	Medicare Advanced Beneficiary Notice (ABN) Include a copy of this form for Medicare patients who have indicated usage of CPAP or BIPAP or another oral appliance within the last five years.
	Medicare Advanced Beneficiary Notice (ABN) Form Instructions OMB Approval Number: 0938-0566 Instructions directly from CMS on how to complete Advanced Beneficiary Notice (ABN).
	Advanced Beneficiary Notice (Participating Providers) BLANK FORM Use this form for patients fitting the description of the document listed above.
	Advanced Beneficiary Notice (Non-Participating Providers) BLANK FORM Use this form for patients fitting the description of the document listed above.
	Advanced Beneficiary Notice for Same or Similar (Participating Providers) SAMPLE The ABN is a notice given to beneficiaries in Original Medicare to convey that Medicare is not likely to provide coverage in a specific case. The ABN may also be used to provide voluntary notification of financial liability for items or services that Medicare never covers. The ABN must be reviewed with the beneficiary or his/her representative and any questions raised during that review must be answered before it is signed. Once all blanks are completed and the form is signed, a copy is given to the beneficiary or representative. In all cases, the notifier must retain a copy of the ABN delivered to the beneficiary on file.
	Advanced Beneficiary Notice for Same or Similar (Non-Participating Providers) SAMPLE Changes and Additions to ABN for a Non-Participating Provider: The last sentence in Option 1 has a single line strike and under Additional Information reads, “This supplier doesn’t accept payment from Medicare for the item(s) listed in the table above. If I checked Option 1 above, I am responsible for paying the supplier’s charge for the item(s) directly to the supplier. If Medicare does pay, Medicare will pay me the Medicare-approved amount for the item(s), and this payment to me may be less than the supplier’s charge.”

ADDITIONAL FORMS

	Symptom Evaluation Questionnaire Use this form for patients document symptoms that the patient presents with.
	Medicare Same or Similar Disclosure Use this form for Medicare patients to rule out Same or Similar equipment usage.
	CPAP Contraindicated Letter Use this form when instructed to do so by a representative from Triton Medical Solutions.
	Provider Authorization Letter (Part 1-of-2) Take the contents of this letter an copy them onto your practice letterhead, then edit the letter to include the details of your practice. Next, either send a copy of the letter (with a copy of the “Provider Authorization Form”) directly to your referring providers, or have your patient hand deliver to their referring provider (which is what we suggest)!
	Provider Authorization Form (Part 2-of-2) Use this form in conjunction with the “Provider Authorization Letter” (Part 1 above).