Health Sqyre CPAP Prescription

 In Most Popular Posts, Sleep Apnea

Many different CPAP products require a CPAP prescription to purchase regardless of whether you use cash or insurance.  When using insurance to pay for any CPAP equipment, a prescription is necessary to provide proof that the patient needs PAP therapy.  The insurance companies refuse to pay for medical devices that patients will not use, which leads to the the rules of CPAP compliance.

Health Sqyre CPAP Prescription

Patient Information


Name: _____________________

Address: _____________________

ZIP: _____________________

Date of Birth: _____________________

Phone: _____________________

City: _____________________

Gender: _____________________

State: _____________________

Email: _____________________

Ordering Physician Contact Information


Name: ___________________________

Email: ___________________________

Address: _____________________

ZIP: _____________________

Phone: _____________________

City: _____________________

State: _____________________

NPI: _____________________

Diagnosis


327.23 Obstructive Sleep Apnea

327.27 Central Sleep Apnea

780.57 Unspecified Sleep Apnea

PAP Equipment & Supplies


MACHINE TYPE AND CORRESPONDING PRESSURE


CPAP (E0601)

BiPAP / Bi-Level / VPAP (E0470)

BiPAP / Bi-Level / VPAP – ST/SV (E0471)

Auto: 4 to 20 cm H20

Non Auto: ___ cm H20

____ IPAP  ____ EPAP

____ IPAP  ____ EPAP


OTHER SUPPLIES


Mask & Other Necessary Supplies (list below)

Other Products: ________________

Heated Humidifier (E0562)

Other Humidifier: ______________


SUPPLIES NECESSARY FOR THE PROPER USE OF PAP EQUIPMENT


Full Face Mask (A7030)

Full Face Cushion (A7031)

Nasal Mask (A7034)

Nasal Pillows (A7033)

Mask Cushion (A7032)

Headgear (A7035)

Chinstrap (A7036)

Tubing (A7037)

Disposable Filters (A7038)

Heated Humidifier Tubing w/ Heated Element (A4604)

Oral Interface (A7044)

Exhalation Port/Swivel (A7045)

Non-Disposable Filters (A7039)

Humidifier Chamber (A7046)


Duration of Use


Lifetime (99 Months)

Limited Duration

________ Years

________ Months


Physician’s Signature: ____________________________

Date: ___________________

Health Sqyre

191 University Blvd., #147 | Denver, CO | 80206

support@healthsqyre.com | 720-507-7718

Downloadable Health Sqyre Prescription Template

Health Sqyre offers a free CPAP prescription template that can be utilized by any patient in need of a prescription.  All you have to do is have it filled out by a licensed medical doctor!

Download Health Sqyre CPAP Prescription Template

doctor holding CPAP prescription

However, if you would like Health Sqyre to go through the trouble of getting you the prescription that you need, please consider our CPAP Prescription Program that will get you a CPAP prescription in less than 48 hours!

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