Carter Sleep CareCPAP & BiPAP · Oklahoma City
Fax: (405) 383-4776
Phone: (405) 688-2105 · Toll-free (866) 791-9455
1409 NW 122nd St, Suite B, Oklahoma City, OK 73114
Referral Cover Sheet
Fax this sheet with the order and documentation to (405) 383-4776.
Referring provider
Name
Practice
NPI
Phone
Fax
Patient
Name
DOB
Phone
Insurance
Member ID
Order details
Device (CPAP / BiPAP)
Settings
Mask preference
Length of need
Documents enclosed
- Signed and dated detailed written order: device (CPAP or BiPAP), pressure settings or auto range, humidifier, mask type, length of need
- Sleep study report showing the diagnosis (AHI/RDI)
- Face-to-face evaluation notes documenting symptoms and the OSA diagnosis
- Patient demographics, phone number, and insurance card (front and back)
Pages sent (including this sheet): ______cartersleepcare.com