AD – Medical Order for Treatment – Provider Signature

Information about Patient

Patient's Name: *

First

Last

Patient's Date of Birth *//

Patient's Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Patient's Cell Phone *

Patient's Home Phone *

Date of Patient's Sleep Test//

Patient's Index of Sleep Apnea on recent sleep test

The index of respiratory disturbance is available from the sleep test report.

Name of Ordering Healthcare Practice: *

Sleep Apnea treatment is governed by the FDA to require a prescription by a licensed healthcare provider.

Address of Ordering Healthcare Practice: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Phone of Ordering Healthcare Practice: *

Name of Ordering Provider: *

First

Last

Ordering Provider's NPI Number: *

Email address for Ordering Provider (Optional)

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.

ICD 10 Code used for Patient Diagnosis (Select one below): *

G47.33 - Obstructive Sleep Apnea (Adult / Pediatric)
G47.31 - Primary Central Sleep Apnea
Other

Enter 'Other' diagnostic code: *

You are seeing this because you indicated 'Other' in the ICD 10 Code item above.

Indicate the type of treatment being ordered. *

PAP Therapy
Oral Appliance Therapy (sometimes referred to as a Dental Appliance)

I'd like to see more details about this medical order (Optional)

I want to review additional details.

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.

Signature of Ordering Provider: *

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 the patient's medical history, there is a medical necessity for treatment of the patient's sleep apnea that was demonstrated during a recent sleep test.

PAP Therapy - Indicate the length of need for PAP therapy: *

90 days
One year
99 months
Other

Indicate the length of need that patient is being ordered to use PAP therapy.

Indicate type of PAP therapy being ordered: *

Auto-titrating PAP - E0601
CPAP fixed pressure PAP - E0601
Auto-titrating Bi-level PAP - E0470

Auto-titrating PAP is an entry-level PAP therapy device continually assessing the patient's airway and delivering a therapeutic pressure within an ordered range determined by the device to resolve a patient's abnormal breathing episodes. CPAP is an entry-level PAP therapy device always delivering an ordered fixed "constant" pressure that has been previously determined to resolve a patient's abnormal breathing episodes. Bi-level PAP may be used for more complex patients, who require higher pressures during inhalation to resolve their abnormal breathing. A bi-level PAP will reduce the pressure delivered when a patient exhales. Providers will order the minimum and maximum pressures to deliver. NOTE: Many insurance plans require a patient to fail on an entry level PAP therapy device prior to accepting an order for bi-level PAP.

Indicate lowest pressure setting in cmH2O for auto-titrating PAP *

The minimum pressure setting capable of being delivered by the auto-titrating PAP is 4 cmH2O.

Indicate highest pressure setting in cmH2O for auto-titrating PAP *

The maximum pressure setting capable of being delivered by the auto-titrating PAP is 20 cmH2O

Indicate fixed pressure setting for CPAP *

A fixed pressure CPAP delivers the selected pressure at all times to the patient during use.

Indicate the iPAP minimum pressure setting in cmH2O for auto-titrating bi-level PAP *

The minimum iPAP pressure setting capable of being delivered by the typical auto-titrating bi-level PAP is 4 cmH2O.

Indicate the iPAP maximum pressure setting in cmH2O for auto-titrating bi-level PAP *

The maximum iPAP pressure setting capable of being delivered by the typical auto-titrating bi-level PAP is 25 cmH2O.

Indicate the ePAP minimum pressure setting in cmH2O for auto-titrating bi-level PAP *

The minimum ePAP pressure setting capable of being delivered by the typical auto-titrating bi-level PAP is 3 cmH2O.

Indicate the ePAP maximum pressure setting in cmH2O for auto-titrating bi-level PAP *

The maximum ePAP pressure setting capable of being delivered by the typical auto-titrating bi-level PAP is 25 cmH2O.

Indicate the minimum pressure support setting in cmH2O for auto-titrating bi-level PAP. *

Pressure Support is the difference between the iPAP and ePAP settings. The minimum pressure support setting recommended by the NIH is to be no less than 4 cmH2O.

Indicate the Initial setup for patient with masks, headgear, and cushions. *

Please fit Mask per patient comfort and include necessary headgear and cushions.
Full Face Mask
Nasal Mask
Nasal Pillows Mask

NOTE: Selecting to "fit mask per patient comfort..." option above precludes the need to select specific "Masks, Headgear and related Supplies." The treatment provider will meet with patient and determine the best mask interface. The treatment provider will then re-present you with the order form to confirm the mask and accessories selected by the patient. If you know the mask and accessories you wish to order then select the mask option you wish to order.

Select a Full Face Mask as well as related Cushion and Headgear: *

Mask Full Face A7030 (1 now)
Cushion Full Face A7031 (1 now)
Headgear Full Face A7035 (1 now)

Most PAP setups for a full face mask typically would require: a Mask, the relevant Cushion and Headgear (each are shown above).

Select a Nasal Mask as well as related Cushion and Headgear: *

Mask Nasal A7034 (1 now)
Cushion Nasal A7032 (1 now)
Headgear Nasal A7035 (1 now)
Chinstrap A7036 (1 now)

Most PAP setups for a nasal mask typically would require: a Mask, the relevant Cushion and Headgear (each are shown above). Some patients may need the optional Chin Strap to keep their mouth closed.

Select a Nasal Pillows Mask as well as related Cushion and Headgear: *

Mask Pillow A7034 (1 now)
Cushion Pillow A7033 (2 now)
Headgear Pillow A7035 (1 now)
Chinstrap A7036 (1 now)

Most PAP setups for a nasal pillows mask typically would require: a Mask, the relevant Cushion and Headgear (each are shown above). Some patients may need the optional Chin Strap to keep their mouth closed.

Do you want to Order the resupply of PAP accessories now? *

Yes
Not at this time

OPTIONAL RESUPPLY SCHEDULE: Select items, if any, for the Mask, Cushion, and Headgear ordered above: *

Mask Full Face A7030 (1 q 90 days)
Cushion Full Face A7031 (1 q 30 days)
Headgear Full Face A7035 (1 q 180 days)
Chinstrap A7036 (1 q 180 days)

If you want to order resupply you would typically order the same Mask, Cushion and Headgear that you selected above. (NOTE: "q" = "every")

OPTIONAL RESUPPLY SCHEDULE: Select items, if any, for the Mask, Cushion, and Headgear ordered above: *

Mask Nasal A7034 (1 q 90 days)
Cushion Nasal A7032 (2 q 30 days)
Headgear Nasal A7035 (1 q 180 days)
Chinstrap A7036 (1 q 180 days)

If you want to order resupply you would typically order the same Mask, Cushion and Headgear that you selected above. (NOTE: "q" = "every")

OPTIONAL RESUPPLY SCHEDULE: Select items, if any, for the Mask, Cushion, and Headgear ordered above: *

Mask Pillow A7034 (1 q 90 days)
Cushion Pillow A7033 (2 q 30 days)
Headgear Pillow A7035 (1 q 180 days)
Chinstrap A7036 (1 q 180 days)

If you want to order resupply you would typically order the same Mask, Cushion and Headgear that you selected above. (NOTE: "q" = "every")

Accessories for PAP Therapy: *

Heated Humidifier E0562 (1 now)
Standard Tubing A7037 (1 now)
Other Accessory(s)

A typical initial patient setup will often include: a Heated Humidifier and tubing. Select "Other" when you want to order additional accessories not on this list.

OPTIONAL RESUPPLY SCHEDULE: Accessories for PAP Therapy *

Replacement water tank (1 q 180 days)
Standard Tubing A7037 (1 q 90 days)
Other Accessory(s) (Recurring)

If you want to order resupply you would typically order the accessories that you selected above. (NOTE: "q" = "every")

Enter Other PAP Accessory(s) *

You are seeing this because you selected "Other Accessory(s)" or "Other Accessory(s) (Recurring)" above.

PAP compliance reporting (select all of the following that apply):

Provide me a PAP compliance report after first 30 days of use.
Provide me a PAP compliance report every six months.
Other

Other PAP compliance reporting: *

You are seeing this because you indicated "Other" in the item above. Enter order for desired additional PAP compliance reporting.

Use the space below to add any additional comments re: patient's sleep apnea treatment.

The above item is optional in case there is anything else you would like to convey about this patient. For example, the best time to contact the patient.

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.

Please review the Medical Order for Treatment

You have been sent this patient referral form by your practice to refer a patient for treatment of their sleep apnea. Please review, revise if needed, authorize, and sign the Medical Order.

Information about Patient

NOTE: This form is a summary of the complete medical order. If you want to see additional details you can click the form item requesting additional details and click the “Submit” button.

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.