Physician Referral Form

DEEPdormir — Physician Referral

Referring Provider Information

Physician:*

Phone:*

NPI #:*

Patient Information

Patient:*

Phone:*

DOB:*

Referral
Reason:

Email:

ICD-10:*

Diagnosis

Obstructive Sleep Apnea (Dx: G47.33)

Upper Airway Resistance Syndrome

Primary Snoring

Suspected TMJ Disorder

Other:

Medical Justification

MAD (E0486) recommended as initial therapy

Patient non-tolerant / non-compliant with PAP

MAD medically necessary in addition to PAP

4yr oral appliance (E0486) necessary; re-eval 36mo

Sleep Apnea

Evaluation & Testing

Oral Appliance Therapy (E0486)

Pediatric Sleep Treatment

Maxillary Expansion

TMJ

Evaluation & Testing

Oral Appliance Therapy

Joint Stabilization

Orthotic Treatment Day

Orthotic Treatment Night

Orthopedic Remodeling

Maxillary, Mandibular Expansion

Orthodontic Treatment

Botox / Trigger Pt. Injections

Dental

Pain

Missing Teeth

Infection

Dental Implants

Dentures / Partials

Dental Bridges

Periodontal Surgery

Restorative Dentistry

Why Refer: For Sleep Apnea

Snoring

Narcolepsy

Daytime Irritability / Mood

Hypersomnia

Hyperactivity / ADD

Gasping / Choking

Nocturnal Enuresis

Excessive Sleepiness

Bruxism (Grinding)

Waking Up Tired

Morning Headaches

Mouth Breathing / Dry Mouth

Weight Gain

RLS / PLMD

Circadian Disorder

Observed Apnea

Disruptive Sleep

Cardiac Arrhythmia

DOT Physical

Bariatric (Pre-op)

Insomnia

CPAP Intolerant / Refuses

Other:

Why Refer: For TMJ

Facial Pain

Ear Pain

TMJ disorders / locking / clicking

Headaches

Jaw joint / muscle pain

Neck / shoulder pain

Burning mouth / tongue

Bruxism / clenching

Dystonia

Other:

Documents Needed for Authorization

Diagnostic Sleep Study

Encounter Notes Prior to Study

Rx for Oral Appliance Therapy

Encounter Notes After Study

Letter of Medical Necessity

Physician Notes

Sleep Study Report

X-Ray / Imaging

Recent Dental Records

☞ This referral form can serve as your prescription for Oral Appliance Therapy

Additional Clinical Notes:

Referring: Physician's Signature

Print Name

Date

Online Referral Form deepdormir.com/referral-form Submit online • Print / Save

Nassau • Suffolk • Queens • Brooklyn

Phone: (516) 548-3028
Email: info@deepdormir.com

Physician Referral — continued

Why Refer: For Sleep Apnea

Snoring

Narcolepsy

Daytime Irritability / Mood Disorder

Hypersomnia (Excessive Drowsiness)

Hyperactivity / Attention Deficit

Gasping / Choking During Sleep

Nocturnal Enuresis (Bedwetting)

Excessive Daytime Sleepiness

Bruxism (Teeth Grinding)

Waking Up Feeling Tired

Morning Headaches

Mouth Breathing / Dry Mouth

Weight Gain

RLS / PLMD (Restless Leg)

Circadian Disorder

Observed Apnea

Distressed Disruptive Sleep

Cardiac Arrhythmia

DOT Physical

Bariatric Surgery (Pre-op)

Insomnia

CPAP Intolerant / Refuses CPAP

Others, please specify:

Why Refer: For TMJ

Facial Pain

Ear Pain

TMJ disorders, limited ROM, locking jaw, joint sounds

Headaches

Pain / soreness around jaw joints & muscles

Neck or shoulder pain

Burning mouth or tongue

Bruxism, clenching, grinding

Dystonia

Others, please specify:

Documents Needed for Authorization

Diagnostic Sleep Study

Encounter Notes Prior to Study

Rx for Oral Appliance Therapy

Encounter Notes After Study

Letter of Medical Necessity

Physician Notes

Sleep Study Report

X-Ray / Imaging (if available)

Recent Dental Records

☞ This referral form can serve as your prescription for Oral Appliance Therapy

Additional Clinical Notes:

Online Referral Form deepdormir.com/referral-form Submit online • Print / Save

Nassau • Suffolk • Queens • Brooklyn

Phone: (516) 548-3028
Email: info@deepdormir.com

100% secure, confidential, and HIPAA compliant.

Submit Your Referral Online

Scan the QR code above or visit:

deepdormir.com/referral-form

(516) 548-3028

Fax: (516) 259-8080

info@deepdormir.com

deepdormir.com

Nassau • Suffolk • Queens • Brooklyn

Intelligent Sleep Health • Dental Sleep Medicine • TMJ Treatment

Online Referral Form deepdormir.com/referral-form Submit online • Print / Save

Nassau • Suffolk • Queens • Brooklyn

Phone: (516) 548-3028
Email: info@deepdormir.com