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Referrals

Ways to Send Orders

Fax

888-323-8429

Email

Intake@
qualitydme.com

Required Documentation

Standard Written Order (SWO)

Signed by Physician
  • Patient name and date of birth
  • Sleep apnea diagnosis selection: OSA or CSA
  • Equipment selection: CPAP, AutoPAP, BiPAP, AutoBiPAP, or BiPAP ST/ASV
  • Treating Practitioner’s signature and date (MD, DO, PA, or NP)

Diagnostic Sleep Study

One of the following:
  • Home Sleep Test (HST)
  • Polysomnography (PSG) report
  • Split-Night Polysomnography (PSG) report

Patient Demographics & Insurance Information

  • Patient contact information (address, home phone, cell, email)
  • A copy of the patient’s insurance card (front and back), if available

Office Visit Notes

Documenting sleep apnea symptoms, medical necessity for testing, and the decision to order a sleep study

Additional Required Documents

Medicare patients only
  • Patient sleep study dated within one (1) year
  • Treating Practitioner’s Face-to-Face visit notes must:
    • Be dated within the last six (6) months
    • Be dated before the HST or PSG (for a new CPAP)
    • Clearly state the medical reason for ordering the sleep study

Notes for Incomplete CPAP Orders:

  • If any required documents are missing, we will notify your office via fax
  • The order will remain on hold until all required documents are received
  • Patients will be updated on their order status periodically

Referral Form

Please fill out the form below and attach all necessary documents: prescription, demographics, insurance information, consultation notes and sleep studies.

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Practice Address*
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