ELEMENTS REQUIRED

1. Date of Rx
2. Patient's Name
3. CPAP/BiPAP Equipment Being Ordered
1. CPAP
2. BiPAP
3. BiPAP with Backup
4. Humidifier
4. CPAP/BiPAP Equipment Settings
5. Supplies can be listed but not required
6. Licensed Practitioner Name or NPI#
7. Signature of Licensed Practitioner

ELEMENTS REQUIRED

1. Date of Rx
2. Patient's Name
3. Patient's Address
4. Patient's Date of Birth
5. CPAP/BiPAP Equipment Being Ordered
1. CPAP
2. BiPAP
3. BiPAP with Backup
4. Humidifier
6. CPAP/BiPAP Equipment Settings
7. Diagnosis for equipment prescribed
8. Supplies can be listed but not required
9. Length of Need (e.g. 99 or Lifetime) or Start Date & End Date is acceptable

10. Ordering Licensed Practitioner Name and Address
11. Signature of Ordering Licensed Practitioner
12. Signature Date of Ordering Licensed Practitioner

ELEMENTS REQUIRED

1. Date of Rx
2. Patient's Name
3. Patient's Address
4. Patient's Date of Birth
5. Patient's Medicaid ID/Policy Number
6. CPAP/BiPAP Equipment Ordered
1. CPAP
2. BiPAP
3. BiPAP with Backup
7. CPAP/BiPAP Equipment Settings
8. Diagnosis for equipment prescribed
9. Supplies can be listed but not required
10. Length of Need (e.g. 99 or Lifetime) or Start Date & End Date is acceptable

11. Licensed Practitioner Name, Address
12. Signature of Licensed Practitioner
13. Signature Date of Licensed Practitioner

ELEMENTS REQUIRED

1. Date be WITHIN 90 Days of setup date (DOS)
2. Patient's Name
3. Patient's Address
4. Patients Medicaid ID/Policy Number
5. CPAP/BiPAP Equipment Ordered
1. CPAP
2. BiPAP
3. BiPAP with Backup
4. Humidifier
6. CPAP/BiPAP Equipment Settings
7. Diagnosis for equipment prescribed
8. Supplies can be listed but not required
9. Specific Therapeutic Objectives
1. (example) To treat OSA
10. Frequency of Use:
1. (example) To use nightly
2. (9 & 10 can be combined: Example: For Nightly Use to Treat OSA)
11. Length of Need (e.g 99 or Lifetime) or Start Date & End Date is acceptable

12. Licensed Practitioner Name, Address
13. Signature of Licensed Practitioner (STAMPS NOT ALLOWED)
14. Signature Date of Licensed Practitioner (STAMPS NOT ALLOWED)