Get Mo Better Sleep Stl Referral Form For Oral Appliance Evaluation 2015-2025

Completing the MO Better Sleep Stl Referral Form For Oral Appliance Evaluation online is a crucial step in obtaining the necessary evaluations for oral appliances. This guide provides a comprehensive walkthrough to ensure accurate and efficient submission.

Follow the steps to fill out the form accurately.

1. Click ‘Get Form’ button to access the form and open it in the online editor.
2. Begin by entering the date at the top of the form in the designated field.
3. Provide the full name of the patient. Ensure you fill in the last name, first name, and middle initial in the respective spaces.
4. Enter the home phone number and cell phone number in the appropriate fields, ensuring accurate formatting.
5. Identify the patient's insurance provider by filling in the name of the provider in the corresponding section.
6. Input the Insurance ID number in the designated field and provide the patient's date of birth.
7. Indicate whether a sleep study is available by marking the appropriate checkbox for 'Yes', 'No', or 'Don't Know'.
8. In the 'Reason for Referral' section, mark all applicable diagnoses, including 'Obstructive Sleep Apnea', 'TMJ', or any other condition by filling in the associated section.
9. List any therapies attempted by marking the relevant options such as 'CPAP', 'None', or 'Surgery'.
10. For non-diagnosed conditions, indicate if the referral is for a consultation or sleep apnea screening.
11. Provide any comments or special concerns in the space provided to ensure all relevant information is communicated.
12. Complete the requesting physician's name by printing it clearly, along with their office phone, office fax, and contact name in the designated fields.
13. Review the completed form for accuracy, save your changes, and choose to download, print, or share the form as needed.

Complete your documents online today for a streamlined evaluation process.