Forms Library
CLINICAL DOCUMENTATION NEEDED FOR PRE-AUTHORIZATION, GAP EXCEPTIONS & CLAIMS
Sleep Apnea (OSA) Documentation Checklist
Use this form as a checklist for all patients who need treatment for OSA.
Epworth Sleepiness Scale
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.
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.
Symptom Evaluation Questionnaire
Use this form for patients document symptoms that the patient presents with.
CPAP Contraindicated Letter
Use this form when instructed to do so by a representative from Triton Medical Solutions.
Provider Authorization Form (Part 2-of-2)
Use this form in conjunction with the “Provider Authorization Letter” (Part 1 above).
TRITON MEDICAL SOLUTIONS
