FORMS LIBRARY

NEW (as of 06/01/2017) – Dental Questionnaire

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.

Member Authorization for a Designated Representative to Appeal a Determination

Include a copy of this form in each patient chart.

Epworth Sleepiness Scale

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.

Provider Authorization Letter (Part 1-of-2)

NEW (as of 02/10/2015): 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 sent 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)

NEW (as of 02/10/2015): Use this form in conjunction with the “Provider Authorization Letter” (Part 1 above).

Nick WagnerForms Library