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Referral Template PAP (Rev 09-16-15) docx 2026
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- Click ‘Get Form’ to open the Referral Template PAP in our editor.
- Begin by entering the patient's information, including their name and date of birth, in the designated fields at the top of the form.
- Select the appropriate diagnosis from the options provided, such as COPD or OSA. If necessary, specify any other diagnosis in the 'Other' field.
- Indicate the length of need for equipment. If it is a lifetime requirement, enter '99' in the corresponding field.
- Fill out the PAP Equipment section by providing values for AHI and RDI, and specify details for CPAP or BIPAP settings as needed.
- Complete the PAP Supplies section by checking off required items based on patient needs and frequency of replacement.
- In the Respiratory Services section, indicate any evaluations or services required and provide comments if necessary.
- Finally, ensure that a physician's printed name, signature, NPI number, fax number, and signature date are filled out before submitting.
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