Patient Referral Form

In order for us to submit to medical insurance and insure a smooth process for the patient, we will require a prescription/referral from your office. If the patient has Medicare as their primary insurance, they must have a face to face encounter to obtain the referral. Please make sure the following is included on the Rx/referral:

  • Patient name
  • DOB
  • “Please evaluate for oral appliance therapy for G47.33”
  • “Patient is CPAP Intolerant and oral appliance therapy is medically necessary to treat obstructive sleep apnea.”

If you wish to fax it to our office, the fax number is 888-390-0424. Alternatively, the patient may bring it to his/her consult with Dr. Levy. Thank you for your cooperation and assistance in helping this patient obtain treatment for their sleep apnea.

Complete the form and we will contact the patient to schedule a consult with Dr. Levy

We are open and seeing patients

Our highest priority is the health and peace of mind of our patients. We want to assure you that we are working with the appropriate agencies, and have taken all measures to properly care for all our patients. 

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