Monterey

Contact Information

[email protected]

408.490.0182

408-624-4545

Hours of Operation

Monday through Friday. 9-5pm

Monterey

101 Wilson Rd, Monterey, CA 93940, USA

Visit Us At One of Our Six Locations

Spark Sleep Solutions is conveniently located throughout the Bay Area with six different locations, including: San Jose, El Camino Hospital – Los Gatos Sleep Clinic, Los Gatos, San Ramon, Santa Cruz, Sunnyvale and Monterey. Contact us to schedule your first appointment for sleep apnea and snoring treatment.

San Jose
Los Gatos
San Ramon
Santa Cruz
Sunnyvale
Monterey

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Sleep Apnea Treatment Near You

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Testimonials
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Physician Referral Form

Oral Appliance Therapy Rx & Medical Necessity Form for Medically Diagnosed Obstructive Sleep Apnea

Requesting Physician's Name:

Requesting Physician's email:

Organization:

Phone:

Fax:

Patient's Name:

DOB (Date of Birth):

Patient's Contact Number:

Notes:

Diagnosis:
Obstructive Sleep Apnea - ICD G47.33Hypersomnia due to Sleep Apnea - ICD G47.10Sleep Apnea/Sleep Related Breathing Disorder, Unspecified - ICD G47.30 (UARS)Sleep Apnea, Other, Unspecified - ICD G47.30Temporomandibular Joint Dysfunction / Orofacial PainOther

Patient's Diagnostic Sleep Study Results (without CPAP or OA):

Date of Study:

Respiratory Disturbance Index (RDI):

Apnea Hyponea Index (AHI):

Lowest O2 Saturation (SpO2):

Statement of Medical Necessity

I am referring the above patient to Dr. Srujal H Shah, DDS INC because I believe it is Medically Necessary for him/her to be
fitted for a custom fitted oral appliance, E0486.

Physician's Signature:

Date:

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