Patient Referral Form
In order for us to submit to medical insurance and insure a smooth process for the patient, we will require a prescription/referral from your office. If the patient has Medicare as their primary insurance, they must have a face to face encounter to obtain the referral. Please make sure the following is included on the Rx/referral:
“Please evaluate for oral appliance therapy for G47.33”
“Patient is CPAP Intolerant and oral appliance therapy is medically necessary to treat obstructive sleep apnea.”
If you wish to fax it to our office, the fax number is 888-390-0424. Alternatively, the patient may bring it to his/her consult with Dr. Levy. Thank you for your cooperation and assistance in helping this patient obtain treatment for their sleep apnea.