FORMS LIBRARY

New (as of 06/04/2018) – Medicare Same or Similar Disclosure Use this form for Medicare patients to rule out Same or Similar equipment usage.
New (as of 06/11/2018 – Medicare Documentation Checklist
Include a copy of this form in each Medicare patients chart who has a diagnosis of Obstructive Sleep Apnea.
New (as of 06/04/2018) 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.

Proof of Delivery Form

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.

CPAP Contraindicated Letter

Use this form when instructed to do so by a representative from Triton Medical Solutions.

Dental Questionnaire

Include a copy of this form in each patient chart who has a diagnosis of Obstructive Sleep Apnea.

Epworth Sleepiness Scale

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.

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).

Nick WagnerForms Library