Physician Referral Form

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










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

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.