Feeling Great Sleep Center

Call: 866-499-1588

Patient Information

Patient Name

Date Of Birth Gender

Address

City

State

Zip

Phone

Other Phone

Insurance Information

Primary Insurance Self Pay?

Policy #

Secondary Insurance

Policy #

Diagnosis Obstructive Sleep Apnea Central Sleep Apnea Mixed / Complex Sleep Apnea

Physician Order

CPAP and Supplies Pressure Setting CM / H20

BiPAP and Supplies Pressure Range IPAP cm EPAP cm

BiPAP ST & Supplies Pressure Range IPAP cm EPAP cm Back up Rate

Humidifier (E0562) Heated (Recommended) Cooled

Order Start Date Length of Need

Mask and Supplies CPAP Mask According to Patient Preference AND All Related Supplies as Listed Below

The following dispensable equipment may be necessary for the proper use of the equipment and is not a part of any PAP machine and needs to be replaced on a regular basis:

(A7027) Combo Oral / Nasal Shell (1 per 3 months)
(A7028) Oral Cushion for Combo (1 per month)
(A7029) Nasal Pillows Combo (2 per month)
(A7030) Full Face Mask Shell (1 per 3 months)
(A7031) Full Face Seal (1 per month)
(A7032) Nasal Seal (2 per month)
(A7033) Nasal Pillows (2 per month)
(A7034) Nasal Shell (1 per 3 months)
(A7035) Headgear (1 per 6 months)
(A7036) Chinstrap (1 per 6 months)
(A7037) Standard Tubing (1 per 3 months)
(A7037) Pressure Line Tubing (1 per 3 months)
(A7038) Disposable Filters (2 per month)
(A7039) Non-Disposable Filters (1 per 6 months)
(A7046) Water Chamber (1 per 6 months)
(A4604) Climate Line Tubing (1 per 3 months)

Physician Information

Physician's Name Practice

Address

City

State

Zip

Phone

Fax

Referral Sent by

Patient's Preferred Location

Contact Details

Durham: 919-477-1588
Toll Free: 866-499-1588
E-Mail: support@FeelingGreatSleepCenter.com

Fax Durham: 919-477-1688
Fax Toll Free: 866-499-1288

Sleep Medical Center Locations: Durham, Burlington, Jacksonville, North Carolina
Feeling Great Respiratory Equipment: Oxygen, CPAP / BiPAP, Nebulizers

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