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9870 x208 homecaremedical.com Ordering Physician Address Phone Patient Information Patient Length of Need Prescription CPAP/BiPAP Order Date Fax Date of Birth Diagnosis q G47. 33 OSA q G47. 31 Central Sleep Apnea q G47. 36 Sleep related hypoxemia/hypoventilation q G47. 10 Hypersomnia For AHI results below 20 a secondary diagnosis of Hypersomnia must be indicated Machine Type q C PAP E0601 cm H2O flex optional q A PAP E0601 Pressure max cm H2O Pressure min cm H2O with flex optional Optistart...

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