Dr. Nancy Addy, DDS
Dr. Jarrett Grosdidier, DDS
Physician Information
Physician Name
Phone
Fax
NPI#
Patient Information
Patient Name
Patient Phone
Date of Birth
The patient referred with this form has been evaluated by the above physician and has been diagnosed to have:
Mild Obstructive Sleep Apnea
Moderate Obstructive Sleep Apnea
Severe Obstructive Sleep Apnea
Simple Snoring
The patient is:
CPAP intolerant
Not a candidate for CPAP therapy
Other
–
explanation
As a physician, I deem this therapy to be medically necessary. Patient is being referred for:
Oral Appliance Therapy
Mouth Closing Device
Home Sleep Test (HST)
Sleep Study
Date of sleep study
Please attach sleep study results
Copies of sleep study results are required for appropriate care. If you do not have the sleep study at the time of submitting this referral, you may return to our website later and separately submit the sleep study on another form.
Physician Signature
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Date
Obstructive Sleep Apnea is a medical condition that tends to become more severe with time and requires periodic re-evaluation by a qualified physician.