Sample CPAP Prescription

To assist members in obtaining the equipment that they need and as a matter of fulfilling equipment preference, a sample CPAP prescription form has been created to use as a tool for patients to submit to their health care provider.

The form may be filled in by the patient to indicate the patient's needs and preferences, then submitted to their doctor who may generate a prescription based on the form.

On the form, you will find a list of equipment commonly used by CPAP patients, corresponding Medicare codes and a generalized replacement schedule.

To fill in the form, indicate with an "X" in the space provided next to the equipment needed. Multiple "X" indications are usually required to specify machine, mask, and tubing. The notes area may be filled in with specific preferences such as "Dispense Resmed Airsense 10 Autoset for Her, do not substitute" and/or "Dispense Resmed Airfit P10, do not substitute".

A downloadable Word file (docx) is available HERE

Health Care Provider

Health Care Doctor

Health Care Address

Health Care City

Health Care Telephone and Fax

Prescription Date:________________ DME:_________________

Patient Name:____________________________

Date of Birth:___/___/_____ Length of Need:________(99=Lifetime)

Diagnosis:_________________________

Equipment Ordered: Frequency

______E0601 CPAP (New or Five year replacement) Per 5 Years

______E0470 BiPAP (New or Five year replacement) Per 5 Years

______E0471 BiPAP ST/SV (New or Five year replacement) Per 5 Years

______E0562 Heated Humidifier (New or Five year replacement) Per 5 Years

Settings:_______________________________

_____A7030 Full Face Mask (Up to ONE every 3 months)

_____A7034 Nasal Mask (Up to ONE every 3 months)

_____A7027 Combination/Nasal Mask (Up to ONE every 3 months)

_____A7035 Headgear (Up to ONE every 3 months)

_____A7037 Tubing (Up to ONE every 3 months)

_____A4604 Heated Tubing (Up to ONE every 3 months)

_____A7036 Chinstrap (Up to ONE every 6 months)

_____A7038 Disposable Filter (Up to TWO every month)

_____A7039 Reusable Filter (Up to ONE every 3 months)

_____A7033 Nasal Pillows (Up to TWO every month)

_____A7046 Humidifier Chamber (Up to ONE every 3 months)

_____A7031 Cushion (Up to ONE every month)

_____A7032 Nasal Cushion (Up to TWO every month)

_____A7027 Combination/Nasal Mask (Up to ONE every 3 months)

_____A7028 Cushion Oral Combination (Up to ONE every month)

_____A7029 Nasal Pillows Oral Combination (Up to TWO every month)

Notes:___________________________________________________________________________________________________________________________________________________

Physician:____________________ NPI:____________________

Physician Signature:_______________________________ Date:___/___/_____

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