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:

REASON FOR REFERRAL (MARK ALL THAT APPLY)


Without Appliance (CPAP or Oral Appliance):

Respiratory Disturbance Index (RDI):
Lowest Desaturation (Sp02):
Apnea Hypopnea Index (AHI):
Percentage of Time Below 90%:
Therapies Attempted:
Surgery:
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: