AU – DropShip Online Medical Order – rev B

HEALTHCARE PROVIDER INFORMATION

A sleep test is governed by the FDA to require a prescription by a licensed healthcare provider.

Name of Ordering Provider *

First

Last

Enter Ordering Provider's NPI Number *

Ordering Provider's Phone *

Ordering Provider's Email (OPTIONAL: Every authorized Ordering Provider has a validated email address on file)

Email

Confirm Email

Every authorized Provider has an email address on file with Snap. When you submit this form, an email will be sent to the Ordering Provider at the email address on file at Snap to allow the Ordering Provider to review, authenticate, authorize and sign this medical order. NOTE: We take online security seriously. ONLY enter an email address above if the email address for the Ordering Provider has changed. If the email address entered above IS NOT the email address on file for the Ordering Provider, someone from Snap will contact the practice to confirm this new email address is a valid email address for the Ordering Provider.

Options to Obtain Ordering Provider Signature:

The Ordering Provider will sign the order now.
Please send the email link to Ordering Provider to sign the Medical Order.
I will later seek a physical signature on this form from Ordering Provider and upload later.
I want to upload a signed medical order now.

This option allows you to determine how to obtain a signature on the Medical Order.

Upload the Signed Medical Order for a Snap Home Sleep Test. *

You are seeing this option because you indicated wanting to upload a signied Medical Order now in the above question.

ORDERING PROVIDER SIGNATURE: *

By my signature above I confirm that I hold a valid healthcare license and I attest that based on my examination of the patient and his/her medical history, there is a high probability of Obstructive Sleep Apnea. An unattended, type 3, Home Sleep Test with a minimum of 4 channels (airflow, respiratory effort, SpO2 saturation and heart rate), is medically necessary. No co‐morbid conditions including, but not limited to, moderate to severe COPD, CHF, OHS, neurodegenerative disorder or cognitive impairment are present that prevent the patient from home sleep testing.

ORDERING PROVIDER SIGNATURE:

By my signature above I confirm that I hold a valid healthcare license and I attest that based on my examination of the patient and his/her medical history, there is a high probability of Obstructive Sleep Apnea. An unattended, type 3, Home Sleep Test with a minimum of 4 channels (airflow, respiratory effort, SpO2 saturation and heart rate), is medically necessary. No co‐morbid conditions including, but not limited to, moderate to severe COPD, CHF, OHS, neurodegenerative disorder or cognitive impairment are present that prevent the patient from home sleep testing.

Test Ordered: Type 3, unattended home sleep test for up to three nights (enter alternative number of nights below). *

CPT Code will be G0399, 95806 or 95800. The ICD‐10 code: Default to G47.30 or Enter other Code below

Check below if you want to see more details about this order for a home sleep test before you sign and authorize the order.

I'd like to see more details about this medical order.

If you want to see more details before you authorize the order, please click the box above and click the "Submit" button below. You'll be presented with all of the elements of the patient's medical order.

PATIENT INFORMATION

Patient Name *

First

Last

Patient Date of Birth *//

Patient Gender Identification *

Male
Female
Other

Patient Cell Phone *

We can text a link to your patient to simplify their registration process for their home sleep test.

Patient Home Phone (Optional)

Patient Email (Optional)

Email

Confirm Email

We can email a link to your patient to simplify their registration process for their home sleep test.

Patient Home Address *

Address Line 1

City

State / Province / Region

Postal Code

This is address where the home sleep test will be sent. We will contact the patient to confirm the best time for the test kit to be delivered.

Patient Height (enter feet)

Patient Height (enter inches)

Patient Weight (in pounds)

Patient Neck Size (in inches) measured at adam's apple

Check all indications that apply for this patient: *

List any other indication(s): *

You are seeing this question because you checked "other indication(s)" in the item above.

Is this a repeat sleep test for this patient? *

Yes
No

It is important to know if this is a repeat sleep test so that we can provide the healthcare insurance provider detailed information regarding the purpose of the repeat sleep test.

Check any reason that applies for indicating the need for this repeat sleep test. *

Patient has significant weight change (10% or more weight gain or loss) since prior test.
Assessment of recent treatment effectiveness.
Determine if patient continues to need previously prescribed therapy.
Patient reports a return of symptoms and medical indications warrant a repeat sleep test.
Other reason for repeat sleep test

Other reason for repeat sleep test: *

You are seeing this question because you indicated above there was an other reason for the repeat sleep test.

Enter any other special instructions you want us to know (Optional).

Please upload the Clinical Note from the face-to-face encounter with the patient when the sleep test was ordered. Please upload only one file for this item.

This information is required by health insurance and will improve the time needed to complete the testing process, when the patient wants to bill their health insurance for the sleep test.

Upload additional file (optional):

Optional - use only if needed to convey information not already provided elsewhere in this form. Please only upload one file for this item.

Does patient have a Medical Insurance Policy?

Yes
No

Please upload the patient's primary medical insurance information.

This can be performed in place of manually entering the patient's Primary insurance plan information. Please upload only one file for this item.

Name of Primary Insurance Company

Primary Insurance Policy Group Number

Primary Insurance ID Number

Name of Insured (If not the patient)

Does patient have a Secondary Medical Insurance Policy?

Yes
No

Please upload the patient's secondary medical insurance card.

This can be performed in place of manually entering the patient's Secondary insurance plan information. Please upload only one file for this item.

Name of Secondary Insurance Company

Secondary Insurance Policy Group Number

Secondary Insurance ID Number

Name of alternative contact to reach patient (Optional)

First

Last

An alternative contact can assist Snap in reaching the patient in a timely manner.

Phone for alternative contact to reach patient (Optional)

If you have a preferred treatment provider AND you want us to forward the test results to this DME please check the box below.

Yes, please forward this Sleep Test Report to the DME indicated below.

NOTE: If you always use the same treatment provider, you can optionally elect to submit a signed letter to Snap and we will automatically send every Test Report to your preferred Treatment Provider.

Enter Company Name of your preferred DME Treatment Provider *

Enter the phone number of your preferred DME Treatment Provider *

Enter the FAX number of your preferred DME Treatment Provider *

Enter Ordering Provider Authorization Code *

When you submit this form, an email will be sent to the address on file for the Ordering Provider. Within 48 hours of receiving the email, the Ordering Provider will be required to click a link on the email and enter this same Code in order to review, revise (if desired or needed), authenticate and authorize this medical order. The Ordering Provider will also be able to sign the medical order at that time.

Complete form and submit to order a home sleep test. After the Ordering Provider authorizes the Medical Order, we will ship the test kit to your patient’s home.

HEALTHCARE PROVIDER INFORMATION

PATIENT INFORMATION

What happens next?

Any patient status updates you enter on your portal are instantly communicated to the Ordering Provider's Patient Portal.

The Master Admin can add an unlimited number of additional login accounts for their organization. Turn notifications ON to get email alerts.

You can transfer any patient to another treatment provider.
The patient will move off your portal and instantly be shown on the portal for the Treatment Provider you selected.
The Ordering Provider's Patient Portal will also instantly reflect the new Treatment Provider.

Sending a patient to Snap for an HST is as Easy as 1, 2, 3.
Select the Ordering Provider for the HST.
Enter a few patient details.
Upload the Medical Order from the Ordering Provider.

This is the information we need to setup the TX Provider Account.
Please gather all of the information shown and send to Snap personnel.