Referral Template PAP (Rev 09-16-15) docx 2025

1. Click ‘Get Form’ to open the Referral Template PAP in our editor.
2. Begin by entering the patient's information, including their name and date of birth, in the designated fields at the top of the form.
3. Select the appropriate diagnosis from the options provided, such as COPD or OSA. If necessary, specify any other diagnosis in the 'Other' field.
4. Indicate the length of need for equipment. If it is a lifetime requirement, enter '99' in the corresponding field.
5. Fill out the PAP Equipment section by providing values for AHI and RDI, and specify details for CPAP or BIPAP settings as needed.
6. Complete the PAP Supplies section by checking off required items based on patient needs and frequency of replacement.
7. In the Respiratory Services section, indicate any evaluations or services required and provide comments if necessary.
8. 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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